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I am not sure if I have understood your question correctly.
I would suggest you to please explain your requirement a bit more in detail and we will surely help you with the required custom css code.
Do you want to simply display the data as displayed in your image or you want to add the textboxes for data input as well? I believe you can just add a matrix field in your form but it will not allow you to add images in matrix field.
You may also like to take a look at the "Configurable List" widget which should help you.
We will wait for your response.