Survey Form -- Basic Sample

Please provide the following:

      
	First Name 
       Last Name 
    Organization 
      Work Phone 
             FAX 
         Your E-mail 
              

How would you rate your interest in these web pages from 
    "1 - not very interested"  to " 5 - very interested"?

1 2 3 4 5

How would you rate your Quality of Life on a scale of 1 to 100 (100 top score)?