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  5. Coffee Survey
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Gender
 
Male
 
Female
 
 
 
What is your date of birth?
 
 
 
Hometown
   
 
 
 
Township
   
 
 
 
Marital Status
 
Single
 
Married
 
Married with children
 
Other
 
 
 
 
Occupation
   
 
 
 
Nationality
   
 
 
 
Do you drink coffee?
 
Yes
 
No
 
 
 
How often do you drink coffee?
 
Occasionally
 
Once a week
 
A few times a week
 
Daily
 
Never
 
 
 
If daily, how many cups of coffee do you drink per day?
 
One cup
 
two cups
 
three cups
 
more
 
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