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Questionnaire template

Feedback and Contact Form

Contact form for sending feedback, complaints, suggestions or questions, with optional reply details and consent.

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Other · Contact forms. All Other templates

Questions in this template

About Your Feedback

  1. We welcome your comments, questions and ideas. Use this form to reach us and let us know if you would like a reply.

  2. What kind of message are you sending?

    Choose one:

    • Compliment
    • Complaint
    • Suggestion
    • Question
    • Other

  3. What kind of message is it?

    Condition: Shown when Other was selected

    Open answer

  4. What is your message about?

    Choose one from a list:

    • Products
    • Customer service
    • Website or app
    • Billing and payments
    • Delivery
    • Other

  5. What topic is your message about?

    Condition: Shown when Other was selected

    Open answer

Your Message

  1. Please write your message.

    Open answer

  2. How would you rate your overall experience with us?

    Choose one:

    • Very poor
    • Poor
    • Fair
    • Good
    • Very good

Getting Back to You

  1. Would you like us to reply to you?

    Choose one:

    • Yes
    • No

  2. Your name

    Condition: Shown when a reply is wanted

    Open answer

  3. How should we contact you?

    Condition: Shown when a reply is wanted

    Choose one:

    • Email
    • Phone

  4. Your email address

    Condition: Shown when email was chosen

    Open answer

  5. Your phone number

    Condition: Shown when phone was chosen

    Open answer

  6. Do you agree that we may use these contact details only to respond to this message?

    Condition: Shown when a reply is wanted

    Choose one:

    • I agree
    • I do not agree