RoboHelp certainly offers the ability to fashion something that would look like that, but you need to know that it's much more involved than making a comments box on the page. There will need to be some sort of database tied into the back end and such a form would then be linked to the database.
Is your example a mock up or one you have actually seen somewhere?
What version of RoboHelp are you using?
Unfortunately you are asking about some pretty significant coding and involvement in creating such a feature. As such, it's unlikely you will find anyone willing to tackle walking you through all the details of how to accomplish such a thing by posting in a forum thread.
Just generically speaking, I might think you would want to investigate the Snippets aspect of RoboHelp. Snippets allow you to put something on multiple pages easily.
yes thats mock up which i want to inserted,and im using robohelp office 11. so thats really complex case right?