1. We do not do homework for users here. That is against the site's rules.
2. We do not do whole projects either. We help with smaller parts of projects. What have you done? What is wrong? What do you need help with? (Not for homework, but for other purposes, you could post in the paid work requests section.)
3. How are you planning to make the form? Do you want to make all of the inputs by hand? Then just type out HTML. If not, since you posted in PHP, then you should look into loops-- in this case, probably a for loop.
4. For more specific help, we will need to see a website or code, not a picture-- we can't guess what's hidden in the image in terms of code. If you have no idea where to start, then see (3)-- that's the first step.