Request to build a Form

How can I make this kind of form?

Please see attached.

Thanks

Allow me some time to build a demo Form for you. I'll get back to ASAP.

Thanks.

tysm.

I have built a demo Form.

https://www.jotform.com/build/90977500372965

Feel free to check and clone the Form.

To clone Form refer to this guide:

https://www.jotform.com/help/42-How-to-Clone-an-Existing-Form-from-a-URL

Thanks.

Is there a way where we can design it in a compact size?

Please take a look at the following cloned form and see if this works as expected:   https://www.jotform.com/90981523084965

Hope this helps. 

Do get back to us if you need any other changes.