How can I create the below fields on a form?

I am trying to create a form with this look to it. They need to be able to check the box on the left and fill in text on the right.

It could be done with native fields:

However, it needs some tweaking, which can be accomplish with the following guides:

https://www.jotform.com/help/90-Form-Field-Positioning 

https://www.jotform.com/help/117-How-to-Inject-Custom-CSS-Codes 

Here is my demo form: https://form.jotform.com/73027294404958 

You can clone it if you want to: http://www.jotform.com/help/42-How-to-Clone-an-Existing-Form-from-a-URL