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 __________________