begin{Form}
      begin{tabularx}{textwidth}{Xcccc}
        toprule
        large textbf{Sozialverhalten} & A & B & C & D \
        midrule
        This is the first survey statement &
          rule[6pt]{0pt}{6pt}hbox{CheckBox[print,name=2, width=0.7em, height=0.7em]{}} &
          rule[6pt]{0pt}{6pt}hbox{CheckBox[print,name=2, width=0.7em, height=0.7em]{}} &
          rule[6pt]{0pt}{6pt}hbox{CheckBox[print,name=2, width=0.7em, height=0.7em]{}} &
          rule[6pt]{0pt}{6pt}hbox{CheckBox[print,name=2, width=0.7em, height=0.7em]{}} \
        midrule
        This is the second survey statement &
          rule[6pt]{0pt}{6pt}hbox{CheckBox[print,name=2, width=0.7em, height=0.7em]{}} &
          rule[6pt]{0pt}{6pt}hbox{CheckBox[print,name=2, width=0.7em, height=0.7em]{}} &
          rule[6pt]{0pt}{6pt}hbox{CheckBox[print,name=2, width=0.7em, height=0.7em]{}} &
          rule[6pt]{0pt}{6pt}hbox{CheckBox[print,name=2, width=0.7em, height=0.7em]{}} \
        midrule
                  [ ... ]
    end{Form}