Web Survey

Service/Utilities Survey Template

Please answer the following questions:

Which of the following best describes the type of customer you are?
Where have you heard about this service? (Choose all that apply)

Why did you purchase this service from us?

How was your overall experience using our institution/agency?

Excellent

Poor

Which of the following features do you like most about the service we provide (choose up to three)?
Which of the following features do you like the least about the service we provide (choose up to three)?
How polite were our employees?
How helpful were our employees?

What were your expectations of the service that we provide?

How well did the service meet your expectations?

Greatly exceeded my expectations
Slightly exceeded my expectations
Met my expectations
Fell slightly short of my expectations
Failed to meet my expectations

How did the service's price compare to your expectations?

More expensive than I expected
Met my price expectations
Less expensive than I expected

How did the price of the service compare to other similar services that you know of?
How much did you pay for your service (not including tax)?

Did you have any coupons or receive any kind of discount?

Yes
No
Not sure

Do you plan to continue using this service?
What would make you more likely to continue using this service?

Would you consider purchasing other utilities through us?

Yes
No
Not Sure

Would you recommend this service to someone else?
Please leave us comments or suggestions for improvement here:

Demographics

Please provide the following demographic information. It will only be used to make statistical comparisons between different groups of respondents; it will not be used to profile individual respondents.

What is your gender?

Male
Female

How old are you?

Which of the following best represents the highest level of education that you have completed?
Are you currently employed?

Yes, full-time
Yes, part-time (30 hours or less per week)
No

What is your marital status?

Married
Single, never married
Widowed
Separated or divorced

What are the age ranges of any children (18 years younger) living in your household? (Choose all that apply)

5 years old or younger
6-12 years old
13-18 years old
Have no children 18 or under living in household

Which of the following best describes your total household income before taxes last year?

Contact Information

This section is optional. Please fill out this section only if you would like us to get in touch with you.

First Name
Last Name
Address 1
Address 2
City
State
Zip / Postal Code
Home Phone
Work Phone
E-mail
Fax

web survey

Friend or colleague	Radio
Word of mouth	Internet
Yellow pages	Billboard
Newspaper	Direct Mail Flyer
Television	Other

Under 20 years	35 - 39	55 - 59
20 - 24	40 - 44	60 - 64
25 - 29	45 - 49	65+
30 - 34	50 - 54

Under $10,000	$40,000 - $49,999	$80,000 - $89,999
$10,000 - $19,999	$50,000 - $59,999	$90,000 +
$20,000 - $29,999	$60,000 - $69,999
$30,000 - $39,999	$70,000 - $79,999