1. Mail or Femail (Circle one)
2. Your Age: (Circle two)
1-5 yrs
5-10 yrs
10-30 yrs
31-35 yrs
36-100 yrs
100-105 yrs
other
3. How many children do you own? (Circle one)
1, 2, 3, 4, 5, 6, 7, 20 or more
4. Would your children eat JWU flavored Cheerios? y, m, n
5. What is your annual household income?
$1,000 - $1500
$1,600 - $1700
$1,700 -$1,800
I'm rich
6. In the next year, do any of your household members plan to buy (check all that apply):
HAM Radio
Commodore 64 Computer
AM/FM Radio
Turntable
Polaroid Camera
VCR
Tape Deck
Walkie Talkies
Calculator
Digital Watch
Lazer Gun
Tape Recorder
Cordless Telephone
110 or 8mm Camera
Flashlight
Car phone
Floppy Diskettes
19" or larger color Television
Walkman
Rollerskates
7. If you had to have your eyes plucked out by crows or you walk down the Vegas Strip naked, which would you choose? Go.
8. Does your household use chewing gum? (yes/no)
9. What sports are your household members into?
Polo
Curling
Disc Golf
Javelin
Hula Hoop
Rollerskating
Origami
Flight
Croquet
Gardening (or extreme gardening)
Amateur Parkour
Calf Roping
10. What hobbies do your household members enjoy?
Poaching
Hang gliding
Ice climbing
Elephant rides
Monkey Training
Skooter Races
BB Gun Tournament
Side walk chalk
Finger Painting
Video Poker
I don't get out much
19. I would like to be notified of special offers & discounts. y/n
email address:___________________
20. How many hours of TV do you watch per day divided by your hours on the internet times 15? ____________
21. Can we contact you about goods and services over telephone? Phone number___________
22. Do you believe in: (circle all that apply)
Aliens
Chupacabre
Santa Claus
Life after love
The Lost City of Atlantis
Humans Evolving from Apes
Pegasus
Unicorns
Leprechauns
Elves
Sprites
Fairies
Trolls
22. Is Superman faster than Flash?
Thank you for taking part in our survey!!! We will enter you in a drawing!
Please place this in a self addresses stamped envelope and mail by March of 2015!
