Adding item, quantity and date required to a service request form

[Lois Ho]

Hello, 

I need to add a field with product, quantity and date required to a service request form. I was able to make the following table using the "create form" function, but each machine and date required needs to be linked to Jira field and only one of the fields can (not all three as per below). 

The requirement for doing this is so we can report on the demand required from each customer (for example customer 1 needs 2x laptops in Dec 22, 3x printers in Jan 23), as well as report on demand for a particular product across the customer portfolio (total laptops required, 5: 2 for customer 1 in Dec 22, 2 for customer 2 in Jan 23, 1 for customer 3 in Feb 23). 

Has anyone done this and can advise how I can set this up?