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 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.