Checkbox list with extra columns for date etc.

I am currently learning all the features of Gravity Forms and have what may be a simple question to answer. I am creating an online form for a doctor's office and want to know how to create a long checklist that includes an extra column for "Date last given". For example, the form includes a list of immunizations for the person to check if they have had that particular shot. It would include a checkbox in the first column, the name of the immunization in the second column (i.e. "Tetanus Shot"), and another column for them to indicate the "Date last given." How could I do that? I tried to find my answer on the forums, but really didn't see an answer to what I'm trying to do. Thanks for your help!

Thanks for the help Chris. I guess that means that each item in the checklist has to be entered individually to be able to create a corresponding Date column. Then I need to apply some specific CSS to the checkboxes and Date fields to make it look more like a single list and not a bunch of individual items.

It works, but is that the easiest way to set it up?