\documentclass[11pt,letterpaper]{article}
  \usepackage{latexsym,geometry}
  \usepackage{fancyhdr,afterpage,pifont}

  \newcommand{\ShortAnswer} {\underline{\hspace{1cm}}\ }
  \newcommand{\checkbox}[1] {$\Box${#1}\hfill}
  \setlength{\parindent}{0pt}
  \renewcommand{\headrulewidth}{0pt}
  \addtolength{\headheight}{1.6pt}

\begin{document}
   \pagestyle{fancy}
     \cfoot{}
     \rfoot{\Pisymbol{pzd}{229} Continues overleaf \Pisymbol{pzd}{229}}
     \afterpage{\rfoot{~\\~\\~\\%
                       \small$\Box$~%
                       I have made more comments on the attached sheet(s)}}

   Today's Date:~\underline{\hspace{35ex}}      %
   \hfill                                      %
   Course:~\underline{\hspace{50ex}}\\
   \begin{center}
   {\bf\Large Mid-semester Teaching Assessment}
   \end{center}

    Please answer these questions carefully.  They will help your professor
    to help you better.  If you need more room to explain something you may
    use the space on the back of this page, or include an extra page of
    your own.

   \begin{enumerate}
     \item About your time in the classroom
         \begin{enumerate}
             \item The explanations in class are\\
               \checkbox{confusing}
               \checkbox{a little helpful}
               \checkbox{somewhat helpful}
               \checkbox{very helpful}

             \item The atmosphere for asking questions in class is\\
               \checkbox{poor}
               \checkbox{fair}
               \checkbox{good}
               \checkbox{great}

             \item The group work during class is\\
               \checkbox{a waste of time}
               \checkbox{somewhat helpful}
               \checkbox{helpful}
               \checkbox{very helpful}

             \item The pace of the class is\\
               \checkbox{very slow}
               \checkbox{slow}
               \checkbox{about right}
               \checkbox{fast}
               \checkbox{very fast}

             \item I attend \ShortAnswer of the classes\\
               \checkbox{very few}
               \checkbox{few}
               \checkbox{most}
               \checkbox{almost all}
               \checkbox{all}
         \end{enumerate}

     \item About the methods of evaluation
         \begin{enumerate}
            \item The amount/length of assignments is\\
                  \checkbox{very light}
                  \checkbox{light}
                  \checkbox{just right}
                  \checkbox{too much}
                  \checkbox{way too much}

            \item The assignments are (check all that apply)\\
                  \checkbox{helpful}
                  \checkbox{challenging}
                  \checkbox{interesting}
                  \checkbox{fun}

            \item The quiz was\\
                  \checkbox{very easy}
                  \checkbox{easy}
                  \checkbox{just right}
                  \checkbox{hard}
                  \checkbox{very hard}
         \end{enumerate}

      \item Office hours
         \begin{enumerate}
             \item If you have not seen the professor during office hours,
                   why not?\\
                  \checkbox{time conflict}
                  \checkbox{haven't needed to}
                  \checkbox{just don't want to}
                  \checkbox{scared to}

            \item If you have seen the professor during office hours, was it\\
                  \checkbox{confusing}
                  \checkbox{a little helpful}
                  \checkbox{somewhat helpful}
                  \checkbox{very helpful}
         \end{enumerate}

      \item About your learning experience
         \begin{enumerate}
             \item So far I am understanding the material\\
               \checkbox{not at all}
               \checkbox{little}
               \checkbox{somewhat}
               \checkbox{very well}

             \item I'm expecting a grade of \ShortAnswer in this class\\
               \checkbox{F}
               \checkbox{D}
               \checkbox{C}
               \checkbox{B}
               \checkbox{A}
         \end{enumerate}

     \item Overall so far, this class is \ShortAnswer\\
          \checkbox{poor}
          \checkbox{fair}
          \checkbox{okay}
          \checkbox{good}
          \checkbox{great}
          \checkbox{best ever}

     \newpage

     \item Something I do not quite understand yet is \ldots
          
           \vspace{\fill}

     \item
           What new things do you think the professor should \emph{start}
           doing to help you learn the material better?
           
           \vspace{\fill}

     \item
           What things does the professor do in class that help you to
           learn the material and that they should \emph{continue} doing?

           \vspace{\fill}

     \item
           Are there any things that the professor does in class that
           they should \emph{stop} doing?

           \vspace{\fill}
   \end{enumerate}

   \hrulefill\\
     If you need more room to explain something please use this space
     or include extra paper:

     \vspace{\fill}

\end{document}
