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.
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Though I am not completely sure what you are looking for, our configurable list widget would be able to create a field similar to what you have in your screen shot:
We also have many templates to help get you started:
If you could let us know a bit more detail regarding how exactly the form should be set up, we can likely help you with whatever you need to add.