Form label from table

Trying to create a form like the one below. Any idea PHPRunner forum community? Thank you.

I. Category name Good Not Good Comment
a. Subcategory name [] [] ___________________________
b. Subcategory name [] [] ___________________________
c. Subcategory name [] [] ___________________________
d. Subcategory name [] [] ___________________________
e. Subcategory name [] [] ___________________________
+ (add new subcategory)

II. Category name
a. Subcategory name [] [] ___________________________
b. Subcategory name [] [] ___________________________
+ (add new subcategory)

Category name = static and taken from table
Subcategory name = static and taken from table
Good / Not Good = check box
Comment = text area
+ = user can add new subcategory name