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Sample Survey #1
(Do not fill this out!)

Survey Topic: Personal Shopping
Number of Questions: 20
Payment for Completing Survey: $20.00


E-Mail address

First Name

Last Name

Mailing address

City, State Zip

1. What is your Gender?
Male
Female

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

3. Which grocery store do you most frequently shop at?
Kroger
Randall's
Albertsons
Hughes
Ralphs
Safeway
Stater Brothers
Vons
Other (please specify)

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. Are online grocery shopping services available in your area?
Yes
No
Don't know

7. Have you ever shopped online for groceries?
Yes
No

8. When you purchase groceries, do you generally...?
Purchase only items you intended to purchase prior to going to the grocery store
Purchase additional items that you see while you are browsing
Purchase additional items that you see advertised

9. Have you ever pulled coupons or special offers from newspapers to use when shopping for groceries?
Yes
No

10. Does the grocery store you visit most frequently offer a frequent shopper program?
Yes
No

11. How would you rate the customer service at the grocery store you frequently shop at?
Excellent
Very Good
Average
Poor

12. Which pharmacy/drugstore do you most frequently shop at?
Eckerds
Longs
Osco
Rite Aid
Savon
Walgreen
Other (please specify)

13. How often do you shop for pharmacy/drugstore products 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

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

15. Are online pharmacy/drugstore services available in your area?
Yes
No

Don't know

16. Have you ever shopped online for pharmacy/drugstore products?
Yes
No

17. When you purchase pharmacy/drugstore products, do you generally...?
Purchase only items you intended to purchase prior to going to the grocery store
Purchase additional items that you see while you are browsing
Purchase additional items that you see advertised

18. Have you ever pulled coupons or special offers from newspapers to use when shopping for pharmacy/drugstore products?
Yes
No

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

20. How would you rate the customer service at the pharmacy/drugstore you frequently shop at?
Excellent
Very Good
Average
Poor

Thank you for taking the time to participate in our survey about personal shopping.


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