Yes, you can create a module with one dimension (list) & 3 line item as text & 1 as Boolean.
when you create a form there is an option to select the list where you want to add new member & also option to choose module. once you choose the module then you will get an option to select the line item.
below you can see there is no item under P3
Once you added the detail, now you can see detail in module.