\documentclass{jarticle}
\usepackage{array}

\newcommand*\checkBoxes{%
\parbox{8cm}{%
\begin{tabular}{*{5}{>{\centering\tiny}m{1.5cm}}@{}l@{}}
良い&やや良い& 普通 &やや悪い &悪い\tabularnewline
\fbox{\normalsize 1} & \fbox{\normalsize 2} & \fbox{\normalsize 3}& \fbox{\normalsize 4} & \fbox{\normalsize 5}\tabularnewline
\end{tabular}%
}}

\begin{document}

\begin{center}
\begin{tabular}{>{\tiny}m{1em} m{2cm} c}
1 & 対応 & \checkBoxes\\[1cm]
2 & 料金 & \checkBoxes\\[1cm]
3 & 味 & \checkBoxes\\[1cm]
\end{tabular}
\end{center}

\end{document}
