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Adding form field to last page of the order process


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I have a customer asking to add a field to the last page of the order process. They asked "Can you put a question on the last page of when customers orders that asks:

 

"How did you find us today?" with a scroll box that has:

"Recent mailing"

"Internet Search"

"Friend/Family Referral"

"Advertisement" with a space to enter the source

"Other" with a space to enter the source...

 

Any help you could provide would be great. I've tried a few things and only seem to make things worse.

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