How to create the following Checkboxes

Hi,
I am trying to create a fremmødeprotokoll.

I need to have something like this.

Names    Date1  Date2  Date3  Date4  Date5  AntallGanger
Name1  chkbox  chkbox chkbox chkbox chkbox:  antall1
Name2  chkbox  chkbox chkbox chkbox chkbox:  antall2
Name3  chkbox  chkbox chkbox chkbox chkbox:  antall3
Name4  chkbox  chkbox chkbox chkbox chkbox:  antall3
Name5  chkbox  chkbox chkbox chkbox chkbox:  antall4

The guys come to school, I check their names and the date. The filed Antall is filled automaticly. This way I know how many times the students have been at school.

I need this in html not script or otherthing, as I dont think vbulletin accepts script in their threads. And this will be thread which I will close so that only I can check the boxes.
any idea?