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HTML

              
                <div class="container">
  
  <div class="form">

    <div class="circle top left"></div>
    <div class="circle top right"></div>
    <div class="circle bottom left"></div>
    <div class="circle bottom right"></div>
    <div class="block b-bottom">
      
      <h1>The Form</h1></div>

    <div class="block b-bottom">
      <input type="text" maxlength="90" placeholder="The ancient art of origami" />
    </div>

    <div id="if-you-can" class="row b-bottom">

      <div class="block fourth b-right">
        <label for="">If You Can:</label>
      </div>

      <div class="block row three-fourths">
        
        <div class="checkbox-item fourth">
          <input type="checkbox" id="a-1" />
          <label for="a-1">Wind</label>
        </div>
        
        <div class="checkbox-item fourth">
          <input type="checkbox" id="a-2" />
          <label for="a-2">Earth</label>
        </div>
        
        <div class="checkbox-item fourth">
          <input type="checkbox" id="a-3" />
          <label for="a-3">Fire</label>
        </div>
        
        <div class="checkbox-item fourth">
          <input type="checkbox" id="a-4" />
          <label for="a-4">Water</label>
        </div>
        
      </div>
    </div>

    <div id="if-you-wont" class="row b-bottom">

      <div class="block fourth b-right">
        <label for="">If You Won't:</label>
      </div>

      <div class="block row three-fourths">
        <div class="checkbox-item half">
          <input type="checkbox" id="b-1" />
          <label for="b-1">Stone</label>
        </div>
        
        <div class="checkbox-item half">
          <input type="checkbox" id="b-2" />
          <label for="b-2">Blood</label>
        </div>

      </div>
    </div>

    <div id="" class="row b-bottom">
      
      <div class="block three-fourths b-right">
        <label class="tag">Family</label>
        <input type="text" maxlength="60" placeholder="" />
      </div>
      
      <div class="block eighth b-right">
        <label class="tag">How</label>
        <input type="text" maxlength="2" class="center-text" placeholder="" />
      </div>
      
      <div class="block eighth">
        <label class="tag">Year</label>
        <input type="text" maxlength="4" class="center-text" placeholder="" />
      
      </div>
    </div>

    <div id="" class="row b-bottom">
      
      <div class="block half b-right">
        <label class="tag">Address</label>
        <input type="text" maxlength="40" placeholder="" />
      </div>
      
      <div class="block fourth b-right">
        <label class="tag">XXX</label>
        <input type="text" maxlength="15" placeholder="" />
      </div>
      
      <div class="block fourth">
        <label class="tag">Grain</label>
        <input type="text" maxlength="15" placeholder="" />
      
      </div>
    </div>

    <div class="row b-bottom" id="moon-div">

      <div class="block two-thirds b-right">

        <ol>
          <li number="1">
            <p>Scry for mooncalves as night falls.</p>
          </li>
          
          <li number="2">
            <p>Reprint</p>
          </li>
          
          <li number="3">
            <p>Assign a warden</p>
          </li>
          
        </ol>

      </div>

      <div class="third" id="moon-div-grid">

        <div class="whole row b-bottom">

          <div class="block third b-right">
            <input type="text" maxlength="4" placeholder="a" />
          </div>

          <div class="block third b-right">
            <input type="text" maxlength="4" placeholder="b" />
          </div>

          <div class="block third">
            <input type="text" maxlength="4" placeholder="c" />
          </div>
        </div>

        <div class=" row b-bottom">

          <div class="block third b-right">
            <input type="text" maxlength="4" placeholder="i" />
          </div>

          <div class="block third b-right">
            <input type="text" maxlength="4" placeholder="ii" />
          </div>

          <div class="block third">
            <input type="text" maxlength="4" placeholder="iii" />
          </div>
        </div>

        <div class=" row">

          <div class="block third b-right">
            <input type="text" maxlength="4" placeholder="α" />
          </div>

          <div class="block third third b-right">
            <input type="text" maxlength="4" placeholder="β" />
          </div>

          <div class="block third">
            <input type="text" maxlength="4" placeholder="γ" />
          </div>
        
        </div>
      </div>
    </div>

    <div class="block"></div>

  </div>

</div>
              
            
!

CSS

              
                @import url(http://weloveiconfonts.com/api/?family=fontawesome);
@import url(https://fonts.googleapis.com/css?family=Fira+Mono);
@import url(https://fonts.googleapis.com/css?family=Montserrat);

/* ----------------- */
/* --- STRUCTURE --- */
/* ----------------- */

body { font-size: 16px; color: #686B5F; background-color: #DBDED3; }

.container { margin: 30px auto; width: 960px; }

.form { 
	position: relative; 
	width: 100%;
	border: 2px solid #7E8272; 
}

.row { display: flex; }
.row.space-around { justify-content: space-around; }

.block { 
	position: relative;
	box-sizing: border-box;
	min-height: 75px;
	padding: 15px;
}

.block.third, .third { width: 33.33%;}
.block.eighth { width: 12.5%; }
.block.fourth { width: 25%; }
.block.half { width: 50%; }
.block.two-thirds { width: 66.66%;}
.block.three-fourths { width: 75%; }
.block.whole { width: 100%; }

.checkbox-item.fourth { width: 25%; }
.checkbox-item.half { width: 50%; }

/* ------------------ */
/* --- TYPOGRAPHY --- */
/* ------------------ */

h1 { 
	margin: 0; padding: 0;
	font-family: 'Montserrat';
	font-size: 32px;
	text-transform: uppercase;
	letter-spacing: 8px;
}

p { margin: 0;}

/* ------------------ */
/* --- DECORATION --- */
/* ------------------ */

/* BORDERS */
.b-top { border-top: 2px solid #7E8272; }
.b-left { border-left: 2px solid #7E8272; }
.b-bottom { border-bottom: 2px solid #7E8272; }
.b-right { border-right: 2px solid #7E8272; }

/* CIRCLES */
.circle {
	width: 10px;
	height: 10px;

	position: absolute;

	background-color: #DBDED3;
	border: 2px solid #7e8272;
	border-radius: 50%;
}

.circle.top { top: -6px;}
.circle.left { left: -6px;}
.circle.bottom { bottom: -6px;}
.circle.right { right: -6px;}

/* --------------------- */
/* --- FORM ELEMENTS --- */
/* --------------------- */

/* General Form Elements */

input[type=text], textarea { 
	width: 100%;
	padding: 15px;
	box-sizing: border-box;

	font-size: 16px;
	font-family: 'Fira Mono';

	background-color: #DBDED3;
	border: none; 
}

input:focus { outline: none;}

::-webkit-input-placeholder {
  font-family: 'Fira Mono' ;
	font-size: 16px;
}

/* LABELS */

label { 
	margin: 0; padding: 0;
	position: relative;
	font-family: 'Montserrat';
	font-size: 18px;
	text-transform: uppercase;
	letter-spacing: 2px;
	}

label.tag {
	position: absolute;
		bottom: 0; left: 0;
	padding: 5px;

	font-size: 12px;
	color: #DBDED3;

	background-color: #7E8272;
}

/* CHECKBOXES */

input[type=checkbox] { 
	width: 30px;
	opacity: 0;
	}

input[type=checkbox]+label:before {
	content: '';
	height: 20px; width: 20px;
	position: absolute;
		left: -40px;

	font-size: 14px;
	text-align: center;
	line-height: 20px;

	border: 2px solid #7E8272;
}

input[type=checkbox]:checked + label:before {
	content: '\f00c';
	font-family: 'FontAwesome';
  padding-left: 2px;
  width: 18px;
}

/* ------------------- */
/* --- INDIVIDUALS --- */
/* ------------------- */

#if-you-can  > div,
#if-you-wont > div { padding-top: 26px; }

/* STEP BY STEP (MOON) */
#moon-div ol {
	height: 211px; /* Height of the three grid rows minus padding */
	display: flex;
	flex-direction: column;
  justify-content: space-between;
	
	padding: 0;
  margin: 0;

	font-family: 'Montserrat';
	font-size: 16px;
	
	list-style: none;
}

#moon-div ol li { 
  position: relative;
  padding-left: 40px;
  height: 50px;
}

#moon-div ol li:before {
	content: attr(number);
  position: absolute;
  left: 0;
	display: inline-block;
	height: 30px;
	width: 30px;

	text-align: center;
	color: #DBDED3;
	background-color: #7E8272;
	line-height: 30px;

	border-radius: 50%;
}

#moon-div ol li p { padding-top: 5px; }

#moon-div-grid input[type=text] { text-align: center;}
              
            
!

JS

              
                
              
            
!
999px

Console