(*) required
1. First Name: *
2. Last Name: *
3. Address: *
Address (line2):
City: *
Zip: *
4. e-mail: *
5. What age group are you in? --- select one --- Under 18 18-25 26-30 31-35 36-40 41-45 46 Plus
6. How often do you shop or buy clothes? --- select one --- Every Week 2 times a month Once a month Other
7. What is the average amount you spend when you shop? --- select one --- Under $50.00 $50 to $75.00 $75.00 to $100.00 $100.00 to $150.00 $150.00 Plus
8. What lines would you like to see the store carry?
9. What makes for a pleasant shopping experience?
10. What is your idea of great customer service?
11. What hours would you like to see the store open?
12. What do you like or dislike about our store?
13. What made you come in to our shop or visit our website?
14. How did you hear about us? --- select one --- Friend E-mail Online Search Advertisement Other
(If you answered Other in Q.14)
15. How likely are you to recommend our store to others. ? --- select one --- Absolutely would Very likely Probably Not likely Would not
16. What reasons would you give them?
17. How satisfied are you with the purchase you made? --- select one --- Very satisfied Satisfied Just ok Not Satisfied Disappointed
18. How satisfied are you with the service you received? --- select one --- Very satisfied Satisfied Just ok Not Satisfied Disappointed
19. How satisfied are you with our company overall? --- select one --- Very satisfied Satisfied Just ok Not Satisfied Disappointed
20. How likely are you to buy from us again? --- select one --- Absolutely would Very likely Probably Not likely Would not
