Crypto Survey

1
What is your name?Leave this blank if you'd like to remain anonymous. Anonymity will void the special gift.
First Name
Last Name
2
What is your email address?Leave this blank if you'd like to remain anonymous. Anonymity will void the special gift.
example@example.com
Email Verified
The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification
••••
Didn't receive verification code?or
Receiving the email may take a few minutes, thank you for your patience!
3
Do you currently use or own any cryptocurrencies?
YESNO
4
What cryptocurrencies to you currently own or use?Leave this blank if you do not wish to provide this information. Please select all that apply. If you choose not to disclose this information, you will still receive the special gift if you provided your name and email.
Bitcoin
Etherium
Dogecoin
Litecoin
I prefer not to disclose this information.
Other
5
Have you used cryptocurrency to make purchases or sales?Leave this blank if you do not wish to provide this information. If you skip this question, but still provided your name and email, you will still qualify for the special gift.
YESNO
6
If Jacob's Audio and Electronics Repair accepted cryptocurrency as a form of payment, how likely would you be to use it?Please select one option.
I would definitely be more likely to pay with cryptocurrency.
I might be likely to use cryptocurrency as a form of payment.
I am undecided about using cryptocurrencies for monetary exchanges.
I would probably not use cryptocurrencies to make payments.
I would definitely NOT use cryptocurrencies as a form of payment.
I only trade cryptocurrencies for financial gain.
I know nothing about cryptocurrencies and have no desire to use them.
Other
7
Do you have anything you'd like to add?Please feel free to add any comments you may have on the subject of cryptocurrencies and/or anything else you might like to mention. Feedback is always appreciated.
Huge
Large
Normal
Small
Ok
Ok
8
Thank you, {whatIs}!

As a special thank you for your responses, please mention the code, "CRYPTO22" when you book your next repair for an additional 20% off. This code can be used for one (1) item to be repaired. If multiple repairs are submitted at the same time, the discount will apply to the repair with the greatest total bill. The bench fee is still required at the time of drop-off, discount will be applied towards the final invoice.

This offer cannot be redeemed for cash and must be used before January 1, 2023. You must book your repair before this time in order to use your discount. If for some reason your item is unrepairable, you will receive this discount off the bench fee. If you cancel the repair for any reason, the discount will not be applied. If you choose not to have the repairs completed when provided with the estimate, the discount will be applied towards the bench fee. If you fail to mention this code before the invoice is paid, the discount will not be applied, but you may use it in the future, if you schedule another repair before January 1, 2023.

Again, thank you for your submission!
9
Thank you!

I appreciate you taking the time to fill out this form. Your answers will help me determine if accepting cryptocurrency would be beneficial to my customers.
Should be Empty:

Thank you, {whatIs}!

Thank you!