You will have to mess around with the header button group width but other then that it looks like the pic you posted. Minus the color...
<div data-role="header">
<div data-role="controlgroup" data-type="horizontal">
<a href="#" data-role="button" class="headerButton">Member</a>
<a href="#" data-role="button" class="headerButton">Subject</a>
<label for="select-choice-0" class="select">Date</label>
<select name="select-choice-0" id="select-choice-0" class="headerButton">
<option value="1">Option 1</option>
<option value="2">Option 2</option>
<option value="3">Option 3</option>
<option value="4">Option 4</option>
</select>
</div>
</div>
<div data-role="footer">
<div data-role="navbar" data-mini="true" data-iconpos="left">
<a href="#" data-icon="edit">Edit</a>
<div data-role="controlgroup" data-type="horizontal" style="float: right;">
<a href="#" data-role="button" data-icon="arrow-l" data-iconpos="left" data-theme="a"> </a>
<a data-role="label">1</a>
<a href="#" data-role="button" data-icon="arrow-r" data-iconpos="right" data-theme="a" data-inline="true"> </a>
</div>
</div><!-- /navbar -->
</div><!-- /footer -->