I wonder if it possible 
Author: R.
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I liked the speed of responses - I wonder if it is possible to make a form like this with software websitex5 - http://www2.bomnegocio.com/ai/form/1
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i had a quick look, not entirly but you can get pritty close.
Why not try it yourself with the demo version ?
http://www.websitex5.com/en/demo-10.html