1. Insert a three-column table with the needed number of rows (including the
empty ones). If it has borders, remove them using Ctrl+Alt+U.
2. Select the entire table and go to Format | Borders and Shading. The
single-line border should be selected unless you've been monkeying around
with something else. Select the desired weight for the gray outline. Select
an appropriate gray as the color. Then click on the All button. This should
give you a light gray grid (similar to the table gridlines.
3. Select the second column. Using the same technique, select a heavy line
weight and black as the color and apply it to the left side. (Note that all
these selections can also be made from the Tables and Borders toolbar.)
4. Select the first cell in the second row (the first empty one) and remove
the Left border. Then select the third cell and remove the Left and Right
borders. If you have table gridlines displayed, you'll have to hide them to
see that you have achieved the desired effect.
5. Continue as above to add top and bottom borders as needed (the heavy
black lines), split cells as required, and so on. And of course you'll have
to drag the column borders to get the appropriate widths.