Sample Form - A Breakfast Example
What is your First Initial?
What is your Last Initial?
Did you have coffee or tea this morning?
Yes
No
I don't remember?
Which one? Coffee or Tea?
Please Select
Coffee
Tea
Neither
How many cups of coffee or tea?
What did you eat for Breakfast?
No Breakfast
Toast
Bagel
Eggs
Bagel
Oatmeal
Fruit
Bacon or Sausage
Cereal
Milk
Other
What food do you wish you could have for breakfast?
How many minutes did it take you to get here?
Approximately what time do you usually eat lunch?
Hour Minutes
AM
PM
AM/PM Option
Submit
Should be Empty: