How to add a check box and an entry field into a question

I have to create a question like this. Need help. 12.B. What is your criterion for defining your businesses? Please check one below and specify the maximum cost for your business. Check box here Followed by entry field Numeric $ _____________________ Check box here Followed by entry field Numeric$ _____________________________ Check box here Followed by entry field Text _______________ Check box here Followed by entry field Other Text __________________