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Focus Group Survey Form
Please fill the form below
Do you or does any member of your household work for:
An advertising or public relations agency
A market research, strategic marketing or opinion company
The marketing or market research department of any company
A telemarketing firm
A food manufacturer or retailer
A software, hardware or multimedia company
Developer or manufacturer
Online retailer
E-commerce or web development company
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Which of the following best describes your age:
Please Select
Under 18
18 - 24
25 - 36
37 - 48
49 - 64
65+
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Do you work full time or part time, outside the home:
Full-time [35+ Hours per week]
Part-time [15-20 Hours per week]
Full-time homemaker
Retired
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Which of the following best describes the highest level of education completed:
Some High School
High School Graduate
Some College
Graduated College
Post Graduate
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Which of the following statements applies to you:
I have children under the age of 6 living at home
I have children between the ages of 6 and 17 living at home
I have no children under the age of 18 living at home
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Do you log on and use the Internet by yourself, without help, at either work or home:
Yes
No
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How long have you been using the Internet, by yourself:
Less than 6 months
6 -12 months
1- 2 years
More than 2 years
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How often do you use the Internet, not including email, by yourself, either at work or at home:
Less than one hour/week
1 - 2 hours/week
2 - 3 hours/week
More than 3 hours/week
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On a scale of 1 to 5, with 1 being the least comfortable and 5 being the most comfortable, how comfortable and familiar are you using the Internet, including such things as links, site addresses, or search engines:
1
2
3
4
5
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When using the Internet, either at home or at work, which do you use more often:
IBM Compatible PC
Mac
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Aside from political surveys, have you participated in any market research studies such as panel discussions, focus groups or surveys, in the last 12 months:
Yes
No
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Name:
First Name
Last Name
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Phone:
This field is required.Please enter value
Invalid phone number.
The value must be less than or equal to 20
EMail:
This field is required.Please enter value
Please enter valid email address
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