Hi Yusuke,
You couldn't make it look exactly like that, but you could add all those fields and have them save to the database.
If you created a pulldown field called "Frequency" with values for (Now, Once, Weekly, Monthly) you could then use the hide/show plugin to show the appropriate date fields for that selection.
http://www.interactivetools.com/add-ons/detail.php?Show-Hide-Dependant-Fields-1035
Hope that helps!
Dave Edis - Senior Developer
interactivetools.com