Name:

Address:

City:

State:

Zip Code:

Email Address:

1. What is your gender?
male
female

2. Which of the following ranges includes your age?
18-24
25-31
32-40
41 or older

3. Are you the primary shopper in your household?
Yes
No

4. How often do you shop for groceries per month?
5 times a month
4 times a month
3 times a month
twice a month
once a month
less often than once month

5. On average, how much money do you spend on groceries in total per month?
under $50
$50 to $100
$101 to $200
$201 to $300
$301 to $400
$401 to $500
$501 or more

6. Have you ever used "BRAND X"?
Yes
No
Don't know

7. How would you rate this product?
Excellent
Very Good
Average
Poor

8. How many times in the past 3 months have you purchased "BRAND X"?
1
2-3 Times
More than 3 times

9. Did you think "BRAND X" was reasonably priced?
Yes
No

10. Have you ever heard of "BRAND Y"?
Yes
No

11. Where did you hear about "BRAND Y"?
Television
Magazine/Print Ad
Internet
Other

12. Which product are you most likely to purchase?
BRAND X
BRAND Y
BRAND Z
BRAND XX
BRAND YY
Other (Please specify)

13. Have you ever purchased any of these products over the Internet?
Yes
No

14. Have you ever pulled coupons or special offers for any of these products?
Yes
No

15. Does the pharmacy/drugstore you visit most frequently offer a frequent shopper program?
Yes
No

This is only a sample, this form will not be submitted and no compensation is provided for this survey. Actual paid surveys may be longer