Form: Client: ABC co. Online Shopping Habits

Part 1: The Basics HEADLINE

Name *

Email *

Do you make online purchases? {yes, no, maybe, always, sometimes}

Part 2: HEADLINE

Phone *

Best time to reach you [am, pm, weekend, do not call]

Title

Marital status {married, single, rather not say}

NOTE We use this information to better serve our customers

What is your age

NOTE We use this information to better serve our customers

What do you like to do for fun

What is your race

NOTE We use this information to better serve our customers

Did you vote in the last election

What are your political beliefs

What is your annual household income

NOTE We use this information to better serve our customers

What is the fastest and most economical Internet service for you?

What planet would you like to visit

What was your last dream about?

What would you do if you won the lottery?

Would you like to build/design your own house?

Which form of public transport do you prefer?

What talents do you have?

Have you ever been admitted to hospital?

Have you ever had any brushes with the law?

Have you ever been on TV?

Have you ever met any celebrities?

Have you ever been to Legoland?

Have you ever done something heroic?

Have you ever played a practical joke on anyone?

Have you ever been the recipiant of a practical joke?

What would be your best achievement to date?

What did you want to be when you grew up?

If you could change anything about yourself what would it be?

Whats the longest you’ve ever grown your hair?

Are you scared of flying?

Would you rather trade some intelligence for looks or looks for intelligence?

Have you ever tie-dyed your own clothes?

How often do you buy new clothes?

Are you reliable?

Are you proud of yourself?

Can you juggle?

Can you solve a rubix cube?

Part 3: HEADLINE

Street Address

City

State

Zip

Country

Religion

Do you use Facebook {all the time, sometimes, almost never, never}

Do you use Twitter {all the time, sometimes, almost never, never}

Do you use Slack {all the time, sometimes, almost never, never}

Do you use Skype {all the time, sometimes, almost never, never}

Do you use Instagram {all the time, sometimes, almost never, never}

Do you use Yahoo {all the time, sometimes, almost never, never}

Do you use Google Plus {all the time, sometimes, almost never, never}

How did you hear about us? {search, friend, TV ad, other}

Twitter name

Linkedin URL

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