How long have you been a customer with us?
Less than 1 year 1-3 years 3-5 years 5+ years Not a customer
What is your favorite product/service from us?
Product A Product B Service C Service D Other
Why do you prefer this product/service?
Quality Price Customer service Convenience Other
How frequently do you purchase/use this favorite product/service?
Daily Weekly Monthly Occasionally Rarely
Would you like to see any improvements or additions to this product/service?
Yes, improvements Yes, additions No, satisfied Not applicable
All set, how can we reach you?
Name
Email
Phone
(Details here)
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