Sample Survey #1

(Do not fill this out!)

E-Mail address

First Name

Last Name

Mailing address

City, State, Postcode

1. What is your Gender?
Male
Female

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

3. 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

4. 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

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

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

7. 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

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

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

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

11. 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

12. 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

13. Are online pharmacy/drugstore services available in your area?
Yes
No
Don't know

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

15. 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

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

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

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