Here is a modified sample from a radio buttons sample posted elsewhere. It matches, I think, the layout you described above. It can be reused for other questions simply by opening it in a text editor and changing the wording or labels of items. If you add or remove items (currently there are 4) just be sure to change the parameter value in your MediaLab questionnaire from (v4) to (vn) where n is the number of questions.
Hope it helps, and please let me know if you have any trouble with it.