Household Item Voting Form
Vote for your preferred household item choice. Please answer all questions to submit your vote. This Household Item Voting Form ensures each response is counted fairly.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Which household item should be purchased next?
*
Vacuum Cleaner
Air Purifier
Coffee Maker
Microwave Oven
Blender
Other
Why did you choose this item?
How important is this item for the household?
*
Not Important
1
2
3
4
Very Important
5
1 is Not Important, 5 is Very Important
Would you be willing to contribute financially to this purchase?
*
Yes
No
Maybe
Select your age group
*
Please Select
Under 18
18-24
25-34
35-44
45-54
55+
How many people are in your household?
*
Do you currently own any of the listed items?
*
Vacuum Cleaner
Air Purifier
Coffee Maker
Microwave Oven
Blender
None of these
Additional comments or suggestions
Submit Vote
Should be Empty: