Customer Loss Survey Evaluation Form
Name
First Name
Last Name
Age
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
What attracted you to become one of our customers?
Marketing and Promotion
Product Variety
Word of Mouth
Brand Value
Product Quality
Pricing
Other
To what extent did each of the following factors influence your decision to stop collaborating with us?
Rows
Not at all
Slightly
Moderately
Very
Extremely
Range of products/services
1
2
3
4
5
Quality of products/services
6
7
8
9
10
After sales support
11
12
13
14
15
Brand Value
16
17
18
19
20
Staff's behavior
21
22
23
24
25
Pricing
26
27
28
29
30
Another company
31
32
33
34
35
Customer service
36
37
38
39
40
Which company/competitor did you switch to now to meet your requirements?
How would you rate this competitor for the following (on a scale of 1 to 5):
Better range of products/services
Lowest
1
2
3
4
Highest
5
1 is Lowest, 5 is Highest
Better quality
Lowest
1
2
3
4
Highest
5
1 is Lowest, 5 is Highest
Better customer service
Lowest
1
2
3
4
Highest
5
1 is Lowest, 5 is Highest
Better prices
Lowest
1
2
3
4
Highest
5
1 is Lowest, 5 is Highest
Will you be willing to resume collaborating with us if we improve the areas where you are displeased?
Yes
No
Maybe
Is there anything else you'd like to share with us that will help us improve the customer experience?
Submit
Should be Empty: