Sample Survey
Topic: ABC Company
Questions: 25
Income For Completing Survey: $35
First Name
Last Name
Mailing Address
City, State, Zip
Email Address
1. Sex?
Male Female2. What Is Your Age Range?
18-24 25-31 32-40 41or Older3. Where Do You Receive Your Prescriptions At?
Wal-MartKmart
Walgreens CVS Pharmacy Eckert Rite-Aid Medicap Other (specify)4. How Often Do You Refill Your Prescription?
12 Times A Year 6 times A Year 3 times a Year Once Or Twice A Year Hardly Ever5. On average, how much money do you spend on Prescription Drugs Each Month
under $60 $60 to $120 $120 to $180 $180 to $250 More? List Amount6. Are Online Pharmacies Available In Your Area?
Yes No No Clue7. Do You Have An Insurance Provider
Yes No If So List Here8. When Picking Up your Prescription You?
Buy Only Your Prescription Grocery Shop As Well Shop With Coupons That Have Been Made Available9. Have You Ever Shopped For Your Prescription Online?
Yes No10. How Often Do You Shop Online For Prescriptions?
Once A Month Once Every 3 Months Twice A Year Yearly11. How would you rate the customer service at the Pharmacy You Usually Go To? Poor Average Very Good Excellent
12. Which Grocery Store Do you Normally Shop At?
Wal Mart Kroeger Kmart Safeway Albertsons Other (specify)13. How often do you shop for Groceries month?
5 times a month 4 times a month 3 times a month twice a month once a month less often than once month14. On average, how much money do you spend on grocery stores?
under $75 $76 to $125 $126 to $200 $201 to $275 $276 to $350 $351 to $450 $451 or more15. Are online pharmacy/drugstore services available in your area?
Yes No Don’t know16. Have you ever shopped online for pharmacy/drugstore products?
Yes No17. When you purchase groceries you…?
Purchase additional items that you see advertised Buy Only What You Came For Browse around and buy what you want18. Have you ever used coupons for groceries
Yes No19. Does the grocery store offer a preferred buyers program
Yes No20. How would you rate the grocery store’s customer service that you normally shop at?
Very Good Good Bad Very Bad