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.
Yes, you can create such jotforms. If you want, you can create mutliple headers as well.
What I would suggest is to take a look at available form templates: http://www.jotform.com/form-templates/ and trying to create something on your own and if you have any questions or need assistance along the way just let us know and we will be happy to help.