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| When was your most recent purchase from [COMPANY A]? |
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| Which of the following items have you purchased from [COMPANY A] in the past year? Select all that apply. |
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| If you have NOT purchased a product from {COMPANY A} within the past year, which statement best explains why? |
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| Which of the following explains why you made your most recent purchase? |
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| How did you make your most recent purchase? |
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| We are introducing a new product, {ENTER NEW PRODUCT NAME AND DESCRIPTION}. How interested would you be in purchasing this item? |
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| What would be an appropriate price range for this product? |
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| Is there anything that does not appeal to you about this product? If so, what? | | |
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| Is there another attribute that you would like to see? If so, what? | | |
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| Please indicate your gender. |
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| Which of the following includes your age? |
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| What is the highest level of education you have completed? |
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| Which of the following categories includes the total annual income of your household before taxes? |
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| Do you have children under the age of 18? |
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| Please share any additional comments for improvements. | | |
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