JotForm is a free online form builder which helps you create online forms without writing a single line of code. No sign-up required.
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I have created a small sample form that is similar to what you are looking for.
You may clone the form and adjust it like you wish.
You can just inject CSS code to it will look the same as your image. If you require assistance injecting CSS code, do let us know. We will be glad to help.