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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 Average
Below Average
Average
Above Average
Well Above Average
N/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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