too long

I need to do a form like the following:

When clicked on the first text box it should display a dropdown

Then if I click in one of the three boxes it should display a calendar as the picture shows:

When clicking on the button it should give me the name chosen from the first box and the days chosen from the different date boxes.

I have no idea idea of how to do the date functionality and my jquery or php do not go as far.

Please help

Use this code for data functionality

  <script src="https://code.jquery.com/jquery-1.12.4.js"></script>
  <script src="https://code.jquery.com/ui/1.12.1/jquery-ui.js"></script>


 <script>
  $( function() {
    $( "#datepicker" ).datepicker();
  } );
  </script>

Date: <input type="text" id="datepicker">