How to Create Following Form
<p>I am new in Android . I have to create following form in Android I search a lot and tried how to put Edit box and Button in Custom View at specify place but as such nothing fruit full .Need Suggestion to create below Form </p>

<p><img src="http://i.stack.imgur.com/EZUSV.png" alt="enter image description here"></p>

<blockquote>
  <p>One Can view form here : <a href="https://docs.google.com/open?id=0B24mKxvBKwivcGtNSWZIOHpiSnc" rel="nofollow">https://docs.google.com/open?id=0B24mKxvBKwivcGtNSWZIOHpiSnc</a></p>
</blockquote>
