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)
Friend or colleague
Word of mouth
Direct Mail Flyer
Why did you purchase this service from us?
How was your overall experience using our institution/agency?
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?
More expensive than some
Neither expensive nor inexpensive
Less expensive than some
How much did you pay for your service (not including tax)?
Did you have any coupons or receive any kind of discount?
Do you plan to continue using this service?
[Goto question UseAgain]
[Goto question UseAgain]
What would make you more likely to continue using this service?
Would you consider purchasing other utilities through us?
Would you recommend this service to someone else?
Please leave us comments or suggestions for improvement here:
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?
How old are you?
Under 20 years
35 - 39
55 - 59
20 - 24
40 - 44
60 - 64
25 - 29
45 - 49
30 - 34
50 - 54
Which of the following best represents the highest level of education that you have completed?
Some high school or less
High school graduate
Attended some college
Are you currently employed?
Yes, part-time (30 hours or less per week)
What is your marital status?
Single, never married
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?
$40,000 - $49,999
$80,000 - $89,999
$10,000 - $19,999
$50,000 - $59,999
$20,000 - $29,999
$60,000 - $69,999
$30,000 - $39,999
$70,000 - $79,999
This section is optional. Please fill out this section only if you would like us to get in touch with you.
District of Columbia
Northern Mariana Is
Prince Edward Island
Zip / Postal Code
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