East Systems Colleges of Rizal

Morong, Rizal
Name (optional): ______________________________________________ Date: ______________________
Address: ________________________________________________________________________________
Dear Customer:
We, the proponents of Aqua Thirst Water Refilling Station are conducting a survey for us to provide
quality drinking water and services that fit your needs and wants. We need your help in filing up this
questionnaire. We appreciate your participation in this survey and welcome your feedback.
Direction: Answer the following question by putting a checkmark () on the box provided that correspond your
answer.
1. Please indicate your age range.
18-24
25-34
35-54
55 or older
2. Please indicate your Gender.
Male
Female
3. How many people are there in your family?
2
4
Others (specify):_____
3
5
4. Please indicate your household income.
P8, 000 and below
P15, 001 P 30,000
P50, 001 and higher
P8, 001 P 15,000
P30, 001 P 50,000
5. Aqua Thirst Water Refilling Station is currently attempting its establishment in Brgy. Quisao, Pililla,
Rizal. Which best describes your opinion of these efforts?
Very positive
I have no opinion
Very negative
Somewhat positive
Somewhat negative
6. Would you consider patronizing a water refilling station if one were located in your barangay?
Yes
No
7. Using the list below what factor/s would most influence you to patronize a water refilling station?
Location
Convenience
Cost
Quality services
Kinds of drinking water
Reputation of water station
8. How aware you are regarding the safety and cleanliness of water you drink?
Very much aware
Aware
Not much ware at all
Much aware
Not much ware
9. From what source does your drinking water comes from?
Pililla Water District
Deep well
Others (specify): _________
Water pump
Water refilling station
10. How frequently do you buy bottled water?
Daily
Once a week
Once a month
Twice a week
Twice a month
11. What size of bottled water do you buy normally?
330 ml
1.5 liters
1.5 gal
500 ml
3 liters
2.5 gal
1 liter
1 gal
5 gal
12. How many bottles (330 ml) of water do you drink per day?
2
4
3
Others(specify):_________
13. In your household, how many bottles (5gal) of water do you consumed in a week?
2
4
3
Others (specify):____________
14. Which kind of water do you prefer to drink?
Purified water
Alkaline water
Mineral water
Distilled water
15. Do you already have purified drinking water dealer?
Yes
No
If yes please specify: ________________
16. Do you agree for 30 minutes time span for the delivery?
Yes
No
17. If we offer purified drinking water, are you willing to try?
Yes
No
18. Will it be possible that you can be our first and loyal customer?
Yes
No
19. How do you want us to reach you to take your order?
Telephone/Mobile
Online
Personal