I'll help you set up the first row. That should get you going.
Create a free format question. You'll need three variables for each row. For the first row, I created a combobox variable named "location1," a textbox variable named "whoate1," and a checkbox variable named "fruit1." Each variable has some subsettings (require response, number of checkboxes, etc.); set these however you need them.
The basic HTML necessary for this first row is this:
<table>
<tr>
<td>
Time Range
</td>
<td>
Location
</td>
<td>
Who Ate
</td>
<td>
Fruit
</td>
</tr>
<tr>
<td>
8:00 - 9:00 am
</td>
<td>
<select name="[% QuestionName() %]_location1" id="[% QuestionName() %]_location1">
<option selected value="">Default text</option>
<option value="1">Home</option>
<option value="2">Office</option>
<option value="3">Vacation</option>
</select>
</td>
<td>
<input name="[% QuestionName() %]_whoate1" id="[% QuestionName() %]_whoate1" type="text" size="20">
</td>
<td>
<table>
<tr class="clickable">
<td class="input_cell">
[% CheckSelect(FreeFormatQ_fruit1, 1) %]
</td>
<td>
Apple
</td>
</tr>
<tr class="clickable">
<td class="input_cell">
[% CheckSelect(FreeFormatQ_fruit1, 2) %]
</td>
<td>
Orange
</td>
</tr>
<tr class="clickable">
<td class="input_cell">
[% CheckSelect(FreeFormatQ_fruit1, 3) %]
</td>
<td>
Grape
</td>
</tr>
</table>
</td>
</tr>
</table>
"FreeFormatQ" should be replaced with the name of the question.