Name: Address: City: State: Zip Code: Email Address:
3. Are you the primary shopper in your household?
Yes No 4. How often do you shop for groceries per month? (select one answer)
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? (select one answer)
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" (select one answer)
Yes No Don't know
7. How would you rate this product? (select one answer)
Excellent Very Good Average Poor
8. How many times in the past 3 months have you purchased "BRAND X" (select one answer)
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"?
11. Where did you hear about "BRAND Y"? (select one answer)
Television Magazine/Print Ad Internet Other
. 12. Which product are you most likely to purchase? (select one answer)
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? (select one answer)
14. Have you ever pulled coupons or special offers for any of these products? (select one answer)
15. Does the pharmacy/drugstore you visit most frequently offer a frequent shopper program? (select one answer)
This is only a sample, this form will not be submitted and no compensation is provided for this survey.
