What is JotForm?
JotForm is a free online form builder which helps you create online forms without writing a single line of code. No sign-up required.
At JotForm, we want to make sure that you’re getting the online form builder help that you need. Our friendly customer support team is available 24/7.
We believe that if one user has a question, there could be more users who may have the same question. This is why many of our support forum threads are public and available to be searched and viewed. If you’d like help immediately, feel free to search for a similar question, or submit your question or concern.
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.