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ptgAsked on June 22, 2015 at 1:42 PM
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David JotForm Support ManagerReplied on June 22, 2015 at 2:53 PM
Please check these two guides to help you create a successful survey form:
A Guideline to Create the Perfect Survey Form - Part 1
A Guideline to Create the Perfect Survey Form - Part 2
The screenshot provided looks more like an order form, just in case, here is a guide regarding payment forms:
http://www.jotform.com/help/165-Setting-Up-Your-First-Order-Form
If you have another question please open a new thread, we will be glad to assist you.