Example Survey: Site Evaluation

What do you think of this site? I'd appreciate your feedback!
Please complete the following survey and click the Send button at the bottom. All questions are optional.

 1   2   3   4   5 For each category, rate this site on a scale from 1 (poor) to 5 (excellent).
How long did
you use this site?
Who are you?
Web browser?
How did you
find this site?
Suggestions,
Comments,
Corrections,
Questions?
Name?
E-mail Address?