Sample Survey from "Sample Automobile Company"
10 Questions - Payment $15
this is just a sample - do not fill out this survey

First name:
Last name:
Address 1:
Address 2:
City:
State:
Zip:
Country:
   

1. Do you, or anyone in your household, drive a car?

 Yes No

(If you answered "no" to the question above, please skip to question 7)

  

2. What brand car do you drive?

 Make:

Model:

Year:

3. How often do you drive your car?

 Rarely
Once a week
Several times a week
Daily
Several times a day
I drive on the job

4. What do you think is the most important feature in an automobile?

 Comfort
Safety
Performance
Looks
Good Value / Price
5. Have you, or anyone in your household been involved in an automobile accident in the last three years? Yes No
6. Considering the vehicle you or someone in your household currently drives, would you say that this vehicle is safe? Yes No
7. On a scale of 1 to 5, how would you rate the importance of safety in a vehicle for you or your family? 1 - Not Important
2 - Somewhat Important
3 - Important
4 - Extremely Important
5 - My top concern
8. Would you be interested in purchasing a vehicle equipped with a new type of safety device? Yes No
9. What is your opinion of the term "Active Safety System"? Dislike
No Opinion
Like
10. Would you pay more for a car equipped with an "Active Safety System" than for one without? Yes No
   
 
  Thank you for completing the survey!

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