Couponic - Yii Framework, add new feature

I currently have a couponic script and I need a small alteration made it to. Basically when the user goes to pay, there is a checkout page, on this page I need a small feature added. At present they choose quantity, and then pay. What i need is at the top a question (which should be specific to that deal - this should be able to be added when you create the deal) On the checkout screen, I would like a dropdown box where the user should be able to select A, B, C (see example image) the form should then be sent as normal e.g. payment taken.... The answer, A, B or C should then be added to the database table, and be viewable in the admin manage coupon table (again see image). Hope that makes sense, and hopefully pretty straightforward for someone who knows what they doing!