Not with just Airtable. You can use a 3rd-party form-maker and store the results in Airtable. 

It depends on how closely you want your form to look like your screen shot. It is possible to use an Airtable form that gathers all the information you wanted (ratings, text, images, etc.), but Airtable forms always present all inputs in a single column, not a pretty layout like you have. 

Our miniExtensions form allows you to display fields side by side for more flexibility regarding the layout of your fields. This way, you would be able to create a form fairly similar to the screenshot you shared without much effort!