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1. How long have you used our [PRODUCTS/SERVICES]?
 
Less than 6 months
 
6 months to less than 1 year
 
1 year to less than 3 years
 
3 years to less than 5 years
 
5 years or more
 
 
 
2. Which of our [PRODUCTS/SERVICES] do you use? Select all that apply.
 
{OPTION 1}
 
{OPTION 2}
 
{OPTION 3}
 
{OPTION 4}
 
{OPTION 5}

 
 
 
3. How frequently do you purchase from us?
 
Every day
 
Every week
 
Every 2 - 3 weeks
 
Every month
 
Every 2 - 3 months
 
Every 4 - 6 months
 
Once or twice a year
 
 
 
4. How would you rate your level of satisfaction with us?
 
Highly satisfied
 
Somewhat satisfied
 
Neutral
 
Somewhat dissatisfied
 
Highly dissatisfied
 
 
5. How much do you rate us on the following attributes?
Well Below Average Below Average Average Above Average Well Above Average
Customer service
Professionalism
Quality of {PRODUCTS/SERVICES}
Understanding customers' needs
Sales staff
Price
 
 
6. Comment:
   
 
 
 
7. How likely are you to continue doing business with us?
 
Very likely
 
Somewhat likely
 
Neutral
 
Somewhat unlikely
 
Very unlikely
 
 
 
8. How likely is it that you would recommend our [PRODUCTS/SERVICES] to a friend or colleague?
 
Very likely
 
Somewhat likely
 
Neutral
 
Somewhat unlikely
 
Very unlikely
 
 
 
9. Do you have any suggestions for improving our [PRODUCTS/SERVICES]?
   
 
 
 
10. What is your gender?
 
Male
 
Female
 
Prefer not to answer
 
 
 
11. Which category describes your age?
 
Younger than 18
 
18 - 24
 
25 - 34
 
35 - 44
 
45 - 54
 
55 - 64
 
65 or older
 
Prefer not to answer
 
 
 
12. What best describes your employment status?
 
Employed full-time
 
Employed part-time
 
Self-employed
 
Not employed, but looking for work
 
Not employed, not looking for work
 
Retired
 
Student
 
Military
 
Homemaker
 
Prefer not to answer
 
Other
 
 
 
 
13. Which of the following categories best describes the industry you work in?
 
Automotive
 
Advertising
 
Consulting Services
 
Education
 
Entertainment
 
Financial Services
 
Government Services
 
Healthcare
 
Human Resources
 
Information Technology
 
Marketing/Sales
 
Non-Profit
 
Pharmaceuticals
 
Public Relations
 
Technical Services
 
Travel
 
Other
 
 
 
 
14. Which category best describes your annual income?
 
Under $15,000
 
$15,000 - $29,999
 
$30,000 - $44,999
 
$45,000 - $59,999
 
$60,000 - $74,999
 
$75,000 - $89,999
 
$90,000 or more
 
Prefer not to answer
 
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