Dynamic Input form - JQuery MySQL PHP

General information for the website: User site
Num. of web pages/modules: 1
Description of every page/module: What I need is a Form that sits inside a parent div that I will be placing into an existing site.
Description of requirements/features: All the form input elements should be in there own div tags. The input elements should be sorted as describe in the attachment. The equivalent to floating left & right simultaneous (not a real thing but there are workarounds that I've included in the attachment).
Extra notes:
I just noticed I uploaded the wrong file. What I uploaded was the first draft. I do not have the final draft now since I am at home but I do have the image. Its very similar but it goes into little more detail regarding formatting. The only other database addition is the Suggestion field. This field will just add suggestions into a table with three fields. User-id, timestamps and suggestion. PDO prepared statements for all inputs is a mist.