[Plugin: WordPress Form Manager] Possible with Form Manager?

I’d like to be able to post a form that contains a list of options with a text field next to each option. I would like for a visitor to be able to enter their name in the field next to an option and then submit. I would like for that option to then disappear for any subsequent viewer. Is this possible with Form Manager? If not, do you know how I can do this?

Thanks!

http://ww.wp.xz.cn/extend/plugins/wordpress-form-manager/