Self-evaluation form - what's the best way to create this?

I need to create a self-evaluation form. A likert scale is what I need, but I can't find any way to print this as one complete document after it is completed. In order to make this readable for the learner I will need to create at least 3 separate slides, which means 3 Likert scales. Is there a way to combine them and print? I've put a sample of the kind of thing I need to do below.

Cleaning the House

Please select the appropriate number:

1 I do this daily     2 I do this weekly     3 I do this monthly

 Wash the dishes               1  2  3

Wipe the kitchen counters          1  2  3

Clean out the refrigerator            1  2  3

Wipe down the stove    1  2  3

Clean the oven 1  2  3

Mop the kitchen floor    1  2  3