CUSTOMER QUESTIONNAIRE
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Purchased Product/Service
Name
First Name
Last Name
How did you hear about our product/service?
Television
Radio
Print advertisement
Online search
Word of mouth
Other
How long have you used our product/service?
Never used
Less than a month
1-3 months
3-6 months
6 months to 1 year
More than 1 year
How did the following factors influence you when selecting your product/service?
Rows
Unimportant
Low Importance
Neutral
Important
Very Important
Price
1
2
3
4
5
Selection
6
7
8
9
10
Customer reviews
11
12
13
14
15
Product packaging
16
17
18
19
20
Customer support options
21
22
23
24
25
Perceived ease of product installation
26
27
28
29
30
Previous experience with brand
31
32
33
34
35
How satisfied are you with the product/service?
Rows
Very Unsatisfied
Unsatisfied
Neutral
Satisfied
Very Satisfied
Quality
36
37
38
39
40
Price
41
42
43
44
45
Selection
46
47
48
49
50
Customer service
51
52
53
54
55
Installation
56
57
58
59
60
First use experience
61
62
63
64
65
How satisfied were you with these aspects of our customer service?
Rows
Very Unsatisfied
Unsatisfied
Neutral
Satisfied
Very Satisfied
Courteous
66
67
68
69
70
Prompt
71
72
73
74
75
Attentive
76
77
78
79
80
Responsive
81
82
83
84
85
Knowledgeable
86
87
88
89
90
How do you prefer to receive information about new products/services?
Direct mail
Email
Social media
Website
Other
Additional comments
Submit
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