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JotForm is a free online form builder which helps you create online forms without writing a single line of code. No sign-up required.
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Can you check our MathJax Widget: http://widgets.jotform.com/widget/mathjax ? Let us know if this works for you. Otherwise, add the choices in the form as an image. This is the easiest way I could think to have this in your form. Adding the equation as an HTML is a bit complicated, but if you want it, let me know and I'll try to find a way. One example is this: http://www.myphysicslab.com/web_math.html.