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How long have you used our [PRODUCTS/SERVICES]?
 
Not yet a customer
 
Less than 6 months
 
6 months to less than 1 year
 
1 year to less than 3 years
 
3 years to less than 5 years
 
5 years or more
 
 
Which of our [PRODUCTS/SERVICES] do you use? Select all that apply.
 
Grain
 
Chemicals
 
None yet
 
Other
    
 
 
How frequently do you purchase from us?
 
Every week
 
Every 2 - 3 weeks
 
Every month
 
Every 2 - 3 months
 
Every 4 - 6 months
 
Once or twice a year
 
Other
    
 
 
How would you rate your level of satisfaction with us?
 
Highly satisfied
 
Somewhat satisfied
 
Neutral
 
Somewhat dissatisfied
 
Highly dissatisfied
 
Does not apply yet
 
 
How much do you rate us on the following attributes?
Well Below AverageBelow AverageAverageAbove AverageWell Above AverageN/A
Customer service-Reception
Customer service-Receiving
Customer service-Delivery
Professionalism
Quality of {PRODUCTS/SERVICES}
Understanding customers' needs
Sales staff
Price
 
Comment:
 
 
 
How likely are you to continue doing business with us?
 
Very likely
 
Somewhat likely
 
Neutral
 
Somewhat unlikely
 
Very unlikely
 
This question does not apply to me yet
 
 
How likely is it that you would recommend our [PRODUCTS/SERVICES] to a friend or colleague?
 
Very likely
 
Somewhat likely
 
Neutral
 
Somewhat unlikely
 
Very unlikely
 
This question does not apply to me yet
 
 
Do you have any suggestions for improving our [PRODUCTS/SERVICES/MARKETING/WEBSITE]?
 
 
 
Contact Information
(please fill in order to receive a discount on your next purchase)
First Name :
Last Name :
Email Address :
 
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