M: Welcome to our example survey. Please answer the questions and submit the survey and you will be allowed to download the results into a spreadsheet on your computer. 
H: General Information 
1. What is your Email address? _________________________________ 
H: Web-based Surveys 
2. Are you interested in doing Web-based surveys? 
{} Yes 
{} No (If no, please skip to Question 6.) 
3. How often do you plan on doing surveys? 
Pull Down 
Once a day 
Once a week 
Once a month 
Once a year 
End Pull Down 
4. Why are you interested in doing surveys? (check all that apply) 
[] Check on customer satisfaction 
[] Find out what my customers want 
[] Other (please specify:) Text Entry Box 
5. How much does it cost for you to do the surveys today?
Designer: $________
Developer: $________
Total: $________
H: Experience 
6. Describe your experience with Web-based surveys 
_____________3;80

H: Thank you
Thank you for talking part in our survey. Please visit our Web site to learn more about doing surveys on the web. <p>Please add additional comments you wish to make here. Also, check over this questionnaire to make sure that you did not accidentally miss a question.