That's almost like the one Rival has. Also there should be choices where you can add why you want your account closed.
It's always so much easier if you already have somethings to chose from. Some have a hard time expressing why, and that is also easier if you don't need to speak directly to anyone.
You maybe are angry, or you don't want to hurt someones feelings. It's tough to be honest sometimes.
You shouldnt have to say why. There's no reason to explain yourself here.