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Website Survey Questionnaire Form
Get feedback from your consumers or customer about your e-commerce website and services. With this form template, customers can quickly give you a feedback, evaluation and other suggestion about your services.
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1
I understand that the following survey is a part of an academic research project. I understand that my responses are anonymous and my participation is completely voluntary.
*
This field is required.
PLEASE NOTE: Some questions require multiple responses.
I Agree
I do not want to participate
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2
How old are you?
Under 18
18 - 24
25 - 34
35 - 44
45 -54
55 - 64
65 - 74
75 or older
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3
What is your gender?
Male
Female
Other
Prefer not to answer
Male
Female
Other
Prefer not to answer
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4
Which of the following best describes your current relationship status?
Married
Widowed
Divorced
Separated
In a domestic partnership or civil union
Single, but cohabiting with a significant other
Single, never married
Married
Widowed
Divorced
Separated
In a domestic partnership or civil union
Single, but cohabiting with a significant other
Single, never married
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5
Which race/ethnicity best describes you?
American Indian or Alaskan Native
Asian / Pacific Islander
Black or African American
Hispanic
White / Caucasian
Multiple ethnicity / Other
American Indian or Alaskan Native
Asian / Pacific Islander
Black or African American
Hispanic
White / Caucasian
Multiple ethnicity / Other
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6
What is your approximate household income?
$0-$24,999
$25,000-$49,999
$50,000-$74,999
$75,000-$99,999
$100,000-$124,999
$125,000-$149,999
$150,000-$174,999
$175,000-$199,999
$200,000 and up
$0-$24,999
$25,000-$49,999
$50,000-$74,999
$75,000-$99,999
$100,000-$124,999
$125,000-$149,999
$150,000-$174,999
$175,000-$199,999
$200,000 and up
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7
What is the highest level of education that you have completed?
Less than high school degree
High school degree or equivalent (e.g., GED)
Some college but no degree
Associate degree
Bachelor degree
Graduate degree
Less than high school degree
High school degree or equivalent (e.g., GED)
Some college but no degree
Associate degree
Bachelor degree
Graduate degree
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8
Which of the following best describes your current occupation?
Office and Administrative Support Occupations
Installation, Maintenance, and Repair Occupations
Legal Occupations
Personal Care and Service Occupations
Building and Grounds Cleaning and Maintenance Occupations
Computer and Mathematical Occupations
Construction and Extraction Occupations
Healthcare Support Occupations
Farming, Fishing, and Forestry Occupations
Arts, Design, Entertainment, Sports, and Media Occupations
Sales and Related Occupations
Community and Social Service Occupations
Life, Physical, and Social Science Occupations
Management Occupations
Food Preparation and Serving Related Occupations
Healthcare Practitioners and Technical Occupations
Business and Financial Operations Occupations
Education, Training, and Library Occupations
Transportation and Materials Moving Occupations
Office and Administrative Support Occupations
Installation, Maintenance, and Repair Occupations
Legal Occupations
Personal Care and Service Occupations
Building and Grounds Cleaning and Maintenance Occupations
Computer and Mathematical Occupations
Construction and Extraction Occupations
Healthcare Support Occupations
Farming, Fishing, and Forestry Occupations
Arts, Design, Entertainment, Sports, and Media Occupations
Sales and Related Occupations
Community and Social Service Occupations
Life, Physical, and Social Science Occupations
Management Occupations
Food Preparation and Serving Related Occupations
Healthcare Practitioners and Technical Occupations
Business and Financial Operations Occupations
Education, Training, and Library Occupations
Transportation and Materials Moving Occupations
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9
What is your zip code?
(Home, work or school)
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10
Are you involved with any community organizations?
Yes
No
Previously, but not currently involved
Yes
No
Previously, but not currently involved
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11
If so, in which organization(s) are you most involved?
(Please include the type of organization and your role)
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12
On a scale of 1 to 5, how would you rate the
level of importance
of each of these community needs areas?
PLEASE NOTE: This question requires multiple responses.
1 - Not Important
2
3
4
5 - Very Important
Child and Family Services
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Senior Support Services
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Physical Health Issues
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Mental Health Issues
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Physical Disability Issues
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Recreation
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Drug Alcohol-Related Issues
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Disaster Services
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Housing
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Transportation
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
Environment
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Row 10, Column 4
Veteran Issues
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Row 11, Column 4
Child and Family Services
Senior Support Services
Physical Health Issues
Mental Health Issues
Physical Disability Issues
Recreation
Drug Alcohol-Related Issues
Disaster Services
Housing
Transportation
Environment
Veteran Issues
1 - Not Important
Row 0, Column 0
2
Row 0, Column 1
3
Row 0, Column 2
4
Row 0, Column 3
5 - Very Important
Row 0, Column 4
1 - Not Important
Row 1, Column 0
2
Row 1, Column 1
3
Row 1, Column 2
4
Row 1, Column 3
5 - Very Important
Row 1, Column 4
1 - Not Important
Row 2, Column 0
2
Row 2, Column 1
3
Row 2, Column 2
4
Row 2, Column 3
5 - Very Important
Row 2, Column 4
1 - Not Important
Row 3, Column 0
2
Row 3, Column 1
3
Row 3, Column 2
4
Row 3, Column 3
5 - Very Important
Row 3, Column 4
1 - Not Important
Row 4, Column 0
2
Row 4, Column 1
3
Row 4, Column 2
4
Row 4, Column 3
5 - Very Important
Row 4, Column 4
1 - Not Important
Row 5, Column 0
2
Row 5, Column 1
3
Row 5, Column 2
4
Row 5, Column 3
5 - Very Important
Row 5, Column 4
1 - Not Important
Row 6, Column 0
2
Row 6, Column 1
3
Row 6, Column 2
4
Row 6, Column 3
5 - Very Important
Row 6, Column 4
1 - Not Important
Row 7, Column 0
2
Row 7, Column 1
3
Row 7, Column 2
4
Row 7, Column 3
5 - Very Important
Row 7, Column 4
1 - Not Important
Row 8, Column 0
2
Row 8, Column 1
3
Row 8, Column 2
4
Row 8, Column 3
5 - Very Important
Row 8, Column 4
1 - Not Important
Row 9, Column 0
2
Row 9, Column 1
3
Row 9, Column 2
4
Row 9, Column 3
5 - Very Important
Row 9, Column 4
1 - Not Important
Row 10, Column 0
2
Row 10, Column 1
3
Row 10, Column 2
4
Row 10, Column 3
5 - Very Important
Row 10, Column 4
1 - Not Important
Row 11, Column 0
2
Row 11, Column 1
3
Row 11, Column 2
4
Row 11, Column 3
5 - Very Important
Row 11, Column 4
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13
On a scale of 1 to 5,
how well
are these areas being served in your local community?
PLEASE NOTE: This question requires multiple responses.
1 - Not well
2
3
4
5 - Very well
Child and Family Services
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Senior Support Services
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Physical Health Issues
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Mental Health Issues
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Physical Disability Issues
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Recreation
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Drug Alcohol-Related Issues
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Disaster Services
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Housing
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Transportation
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
Environment
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Row 10, Column 4
Veteran Issues
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Row 11, Column 4
Child and Family Services
Senior Support Services
Physical Health Issues
Mental Health Issues
Physical Disability Issues
Recreation
Drug Alcohol-Related Issues
Disaster Services
Housing
Transportation
Environment
Veteran Issues
1 - Not well
Row 0, Column 0
2
Row 0, Column 1
3
Row 0, Column 2
4
Row 0, Column 3
5 - Very well
Row 0, Column 4
1 - Not well
Row 1, Column 0
2
Row 1, Column 1
3
Row 1, Column 2
4
Row 1, Column 3
5 - Very well
Row 1, Column 4
1 - Not well
Row 2, Column 0
2
Row 2, Column 1
3
Row 2, Column 2
4
Row 2, Column 3
5 - Very well
Row 2, Column 4
1 - Not well
Row 3, Column 0
2
Row 3, Column 1
3
Row 3, Column 2
4
Row 3, Column 3
5 - Very well
Row 3, Column 4
1 - Not well
Row 4, Column 0
2
Row 4, Column 1
3
Row 4, Column 2
4
Row 4, Column 3
5 - Very well
Row 4, Column 4
1 - Not well
Row 5, Column 0
2
Row 5, Column 1
3
Row 5, Column 2
4
Row 5, Column 3
5 - Very well
Row 5, Column 4
1 - Not well
Row 6, Column 0
2
Row 6, Column 1
3
Row 6, Column 2
4
Row 6, Column 3
5 - Very well
Row 6, Column 4
1 - Not well
Row 7, Column 0
2
Row 7, Column 1
3
Row 7, Column 2
4
Row 7, Column 3
5 - Very well
Row 7, Column 4
1 - Not well
Row 8, Column 0
2
Row 8, Column 1
3
Row 8, Column 2
4
Row 8, Column 3
5 - Very well
Row 8, Column 4
1 - Not well
Row 9, Column 0
2
Row 9, Column 1
3
Row 9, Column 2
4
Row 9, Column 3
5 - Very well
Row 9, Column 4
1 - Not well
Row 10, Column 0
2
Row 10, Column 1
3
Row 10, Column 2
4
Row 10, Column 3
5 - Very well
Row 10, Column 4
1 - Not well
Row 11, Column 0
2
Row 11, Column 1
3
Row 11, Column 2
4
Row 11, Column 3
5 - Very well
Row 11, Column 4
1
of 12
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14
If you could change one thing about your community, what would it be?
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15
Has the COVID-19 pandemic affected the needs of your community? If so, how?
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16
Do you have any other comments, questions, or concerns?
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