Central Surveys, Inc.

Central Surveys, Inc.
111 North Elm
Shenandoah, IA 51601

Ph: 800-850-8087
(or) 712-246-1630
Fax: 712-246-5420

If you are considering a telephone survey, please fill out
the following information that would apply to the work you would like quoted.
When you are ready to submit the information, click on the submit button to send.
We will respond to your request within the same working business day.
(A valid email address, day contact phone number and contact name are required.)

(For a sample of what Central Surveys, Inc. can do for you, please click here.)

Audience description/ type of respondent:
Approximate number of interviews you would want us to complete:
Approximate length of the questionnaires, minutes required to administer, or how many questions there would be:
Would you allow the survey sponsor to be identified at beginning of interview?	Yes No Undecided at this time
Will there be a monetary or other incentive for respondents?	Yes No Undecided at this time
Approximately how many "open-ended" questions would be included?
Will quotas exist?	Yes No Undecided at this time
If yes, what are they? (Press check all that apply)	By age By gender By location By income Other categories
What are the qualifiers? (Ex. Respondent cannot be employed by XYZ Marketing Research Firm)
Would sample be provided by the client?	Yes No Not known at this time
Would sample include telephone numbers?	Yes No Not known at this time
If select audience, would sample be pre-screened (pre-qualified)?	Yes No Not known at this time
What would your expectations be as to the results? (Press check all that apply)	Full report Tabs only Data only Other Typed verbatim to open-ended questions
What is the expected time frame?
Your business/organization's name:
Name of contact person: (required)
Day phone number: (required)	- -
Extension number: (optional)
Email address: (required)
Business/organization's postal mailing address:
Any additional questions or comments that you would like us to be aware of: