SURVEY QUESTIONNAIRE
A structured questionnaire to gather responses for a survey or research study; responses are used only for the stated purpose and kept confidential.
Survey Title: [Survey Title]
Purpose: [Brief statement of what the survey aims to find out]
Date: [DD/MM/YYYY]
Section A - Respondent Profile
Name (optional): [Name] Age Group: [ <25 ] [ 25-40 ] [ 41-60 ] [ 60+ ]
Gender: [ Male ] [ Female ] [ Other ] City/State: [Location]
Occupation: [Occupation]
Section B - Multiple Choice
Q1. [Question]? [ Option A ] [ Option B ] [ Option C ] [ Option D ]
Q2. How often do you [activity]? [ Daily ] [ Weekly ] [ Monthly ] [ Rarely ] [ Never ]
Section C - Rating (1 = Strongly Disagree, 5 = Strongly Agree)
Q3. [Statement]: [ 1 ] [ 2 ] [ 3 ] [ 4 ] [ 5 ]
Q4. [Statement]: [ 1 ] [ 2 ] [ 3 ] [ 4 ] [ 5 ]
Section D - Open Ended
Q5. [Open question]? [Your Answer]
Q6. Any suggestions? [Your Answer]
How to use: Keep the purpose statement short, mix closed and open questions, and place demographic questions first. Assure confidentiality to improve the response rate.