1) Would you be interested in buying this product or service?    Yes   No

Note the following about the person you are interviewing:

Gender: Male   Female
Age:      4-10   10-18   19-25   25-35   35-50   50-65   65-75  Over 75
In what part of town do you live?
Family Status: Single   Couple (no kids)   Couple (kids at home)   
                          Couple (grown kids)

Notes:

2) How far would you travel to purchase my product or service?

   1-5 miles    6-10 miles     11-15 miles    more than 15 miles 
  Would by on-line    Would order by telephone   Other Response

Notes:

3) How often would you purchase my product or service?

   Only once   Weekly     Monthly   Every 3 months 
  Every 6 months    Other Response

Notes:

4) When would you be most likely to purchase from me?

Day(s) of Week:
Month of year:
Time of day:
 Other response:

5) Are you interested in this product for

Yourself
Your home
Your business
 Your child
 Other family member
As a gift
Other

6) Why would you buy this product or service?

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