Name of Organization Requesting Information

Information Survey

The purpose of this survey is to collect information from you about something. The purpose of this survey is to collect information from you about something. The purpose of this survey is to collect information from you about something. The purpose of this survey is to collect information from you about something. The purpose of this survey is to collect information from you about something. The purpose of this survey is to collect information from you about something.

This survey is divided into the following sections:

Fill out the information in each section as requested. Then at the end of the form supply your name and contact information, and submit the form. You will receive a confirmation message from us shortly.

SECTION A -- Title of this section

These are the instructions for filling out this section. These are the instructions for filling out this section.These are the instructions for filling out this section.

  1. What is your favorite TV show?



  2. How many hours of television do you watch per week:

    None 1-5 hours 5-10 hours 10-20 hours More than 20 hours

  3. We would like to send you some literature. What is your mailing address? 
    Name     
Street   
City     
State    
Zip Code
Back to Top

SECTION B -- Title of this section

These are the instructions for filling out this section. These are the instructions for filling out this section. These are the instructions for filling out this section.

  1. How would you rate this survey?

    Bad Poor Fair Good Excellent

  2. What is your favorite color?



  3. Select the subject areas you are most interested in:

    History
    Geography
    Mathematics
    Economics
    Literature

  4. Here's another way of collecting address info without using fixed-width text:

    Username
    Password
Back to Top

SECTION C -- Title of this section

These are the instructions for filling out this section. These are the instructions for filling out this section. These are the instructions for filling out this section.

  1. Which of our products do you currently own? 
    SKU-01     SKU-04     SKU-07     SKU-10
SKU-02     SKU-05     SKU-08     SKU-11
SKU-03     SKU-06     SKU-09     SKU-12
  2. Please enter any additional comments regarding our products or services:



  3. Select a month from the following list, which shows 6 elements at a time:

Back to Top

FORM SUBMISSION

Thank you for taking the time to answer the questions in our survey.

This explains how we plan to use the information you provide to us. We will also explain what benefits you receive from helping us in this way.

Back to Top
Author information goes here.
Copyright © 1995 [OrganizationName]. All rights reserved.
Revised: .