Can CKForms do this?

[YBA]

Hello

I am using Joomla and Virtuemart.

I would like to add a short form to the last page of the Virtuemart checkout process.

Basically 1 question with 6 or so answers - How did you find our site?

I would like to collect this information to gauge the effectiveness of our advertising.

Would it be possible to do this with CKForms?

Regards
Danielle