How can I add check boxs and text box in the answers?

Here's what I'd like my question and answers to look like:
Q:   Please list all the times that you usually eat during the week, and whether it is a meal or snack:
____ (time) ☐ meal ☐ snack
____ (time) ☐ meal ☐ snack
____ (time) ☐ meal ☐ snack
____ (time) ☐ meal ☐ snack