Your Name

[Your Name]

Email Address

Company Name

Date

1. Which products or services have you purchased from us in the past? (Check all that apply)

• [Product/Service Name]

• [Product/Service Name]

• [Product/Service Name]

• [Product/Service Name]

• Other (Please specify):

2. How satisfied are you with the products or services you've purchased?

• Very Satisfied

• Satisfied

• Neutral

• Dissatisfied

• Very Dissatisfied

3. What factors influence your decision to purchase from us? (Check all that apply)

• Product Quality

• Pricing

• Customer Service

• Brand Reputation

• Product Features

• Warranty/Guarantee

• Recommendations

• Other (Please specify):

4. How often do you make a purchase from us?

• Daily

• Weekly

• Monthly

• Occasionally

• Rarely

5. What is your preferred method of communication for receiving updates and promotions? (Check all that apply)

• Email

• SMS/Text

• Social Media

• Phone Calls

• Direct Mail

• None

6. Do you have any specific product or service requests or suggestions for improvement?

[Write Down Your Response Here]

7. How likely are you to recommend our products or services to others?

• Very Likely

• Likely

• Neutral

• Unlikely

• Very Unlikely

[Write Down Your Response Here]