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Are you:
 
Male
 
Female
 
 
 
Did you receive this product as a gift?
 
Yes
 
No
 
 
 
How did you first discover this product was available for purchase?
 
Advertising - TV, newspaper, magazine, radio
 
Ad in another (product) - brochure, preview
 
Friends/Family/Someone told me about it
 
Read a magazine article/review
 
Saw it in the store/Browsing in store
 
Through the mail/mail catalog
 
Other
 
 
 
What is the one reason you purchased this (product)?
 
Someone asked for it
 
Makes a great gift
 
Own other (products) and wanted more
 
It is a classic
 
Good for the whole family
 
Saw it in the store
 
I like the (product)
 
Price/Good value
 
Other
 
 
 
 
   
 
 
 
 
   
 
 
 
 
   
 
 
 
 
   
 
 
 
 
   
 
 
 
Your age:
 
12 yrs. or younger
 
13-17 yrs.
 
18-24 yrs.
 
25-34 yrs.
 
35-44 yrs.
 
45-54 yrs.
 
55-64 yrs.
 
65+ yrs.
 
 
 
What is your annual household income?
 
Below $20,000
 
$20,000-$29,999
 
$30,000-$39,999
 
$40,000-$49,999
 
$50,000-$74,999
 
$75,000-$99,999
 
$100,000-$149,999
 
$150,000+
 
 
 
Overall, how would you rate [COMPANY]?
 
Excellent
 
Good
 
Average
 
Poor
 
Terrible
 
 
 
How satisfied are you with your service from [COMPANY]?
 
Extremely satisfied
 
Very satisfied
 
Neutral
 
Very dissatisfied
 
Extremely dissatisfied
 
 
 
Would you recommend [COMPANY] to a friend?
 
Yes
 
No
 
 
 
If no, why not?
   
 
 
 
For your NEXT [PRODUCT] purchase, how likely are you to purchase from [COMPANY]?
 
Very likely
 
Somewhat likely
 
Not sure
 
Somewhat unlikely
 
Very unlikely
 
 
 
What are the THREE main reasons you didn't purchase [PRODUCT] from [COMPANY]?
   
 
 
 
If you could change something about [COMPANY] what would it be?
   
 
 
 
Are there any other comments you have for [COMPANY]?
   
 
 
 
How long have you used [PRODUCT]?
 
Less than 1 month
 
1 to 6 months
 
6 months to 1 year
 
1 to 3 years
 
Not sure
 
Never used
 
Other
 
 
 
 
How often do you use [PRODUCT]?
 
Daily
 
Once/week
 
2 to 3 times a month
 
Once/month
 
Ever 2-3 months
 
2-3 times a year or less
 
Not sure
 
Other
 
 
 
 
Overall, how satisfied are you , with [PRODUCT/SERVICE]?
 
Very satisfied
 
Satisfied
 
Neutral
 
Dissatisfied
 
Very dissatisfied
 
Not sure
 
 
 
How likely are you to use/purchase [PRODUCT] again?
 
Definitely
 
Probably
 
Not sure
 
Probably not
 
Definitely not
 
Never used
 
 
 
Would you recommend [PRODUCT OR SERVICE] to others?
 
Definitely
 
Probably
 
Not sure
 
Probably not
 
Definitely not
 
Never used
 
 
 
What recommendations would you offer for improving [PRODUCT/SERVICE]?
   
 
 
 
Thank you for your feedback.
 
 
 
How familiar are you with [PRODUCT]?
 
Never heard of it
 
I am aware but have never used it
 
Use it only sometimes
 
Use it on a regular basis
 
 
 
Which of these[GENERIC_PRODUCT] have you used?
 
[ENTER BRAND 1]
 
[ENTER BRAND 2]
 
[ENTER BRAND 3]
 
[ENTER BRAND 4]
 
[ENTER BRAND 5]
 
[ENTER BRAND6]
 
Other
 
 
 
 
How did you first hear about [PRODUCT]?
 
TV
 
Radio
 
Magazine
 
Newspaper
 
Internet
 
Friend/relative/associate
 
Haven't heard of it before
 
Not sure
 
Other
 
 
 
 
Overall, how do you rate the quality of [PRODUCT]?
 
Poor
 
Fair
 
Good
 
Very Good
 
Excellent
 
 
 
What is it that you would most like to change about [PRODUCT]?
   
 
 
 
How often do you buy [PRODUCT]?
 
Once per week or more often
 
2 to 3 times per month
 
Once per month
 
Once every 2-3 months
 
Once or twice a year
 
Less than once a year
 
Not sure
 
 
 
How likely are you to buy [PRODUCT] in the future?
 
Very Unlikely
 
Somewhat Unlikely
 
Not sure
 
Somewhat likely
 
Very likely
 
 
 
Over all, how satisfied are you with [PRODUCT]
 
Very satisfied
 
Somewhat satisfied
 
Neutral
 
Somewhat dissatisfied
 
Very dissatisfied
 
 
 
What are some aspects of [PRODUCT] that can be improved?
   
 
 
 
Based on your experience, how does [PRODUCT] compare with [OTHER_BRAND_PRODUCT]?
 
[PRODUCT] is better
 
About the same
 
[PRODUCT] is worst
 
Not sure
 
 
 
Which of the following attributes enticed you to try the [PRODUCT] (initially)?
 
Looks good
 
Easy to use/convenient
 
Price Value
 
Solves Problem
 
Readily available
 
Best quality
 
Good selection
 
Just what I need
 
Advertising
 
Not sure
 
Other
 

 
 
 
Comments:
   
 
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