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Date category combination

 

Hello everyone,
 
Please how can I design a form with a Date Category or category combination as below ?
 
Sincerely, 
|     |  (Under 1)  |  (1-5)  |  (Over 5)  |  Date

  |
|  Dataelement1  |  #  |  #  |  #  |  __/___/____  |
|  Dataelement2  |  #  |  #  |  #  |  __/___/____  |
|  Dataelement3  |  #  |  #  |  #  |  __/___/____  |
|  Dataelement4  |  #  |  #  |  #  |  __/___/____  |
|  Dataelement5  |  #  |  #  |  #  |  __/___/____  |

 ========================= EKANI Guy 




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