Can you create a webform which combines a check box list with a text field?

In Business Catalyst I'm looking to create a question and answer web form where visitors to the site fill out a choice or choose other and fill in a text field. See sample below...
Has anyone got any suggestions on how this could be done?
The question would be as follows...
Do you live in the area?
_ Yes
_ Cottager
_ Visiting
_ Other Location _____________

Liam,
Thanks for your response, now I'm finding out from the client that this is really an anonymous survey that they want to put on the site. They have been using an online survey but it keeps asking people to join by email. They are getting complaints about that so they want to find another way.
I've tried to make the form anonymous but I can't remove the email field. Can this be hidden so it doesn't show. Or is there another way to do this?
I'm not able to code javascript and there are other questions which are similar to the sample I gave which require a text field as well as check boxes.

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