Sample - Feedback Form with Confirmation

ABC Company

Thank you for giving us your feedback. Your feedback is important to us. Please take a few minutes to complete this questionnaire.

You will receive a confirmation code after you submit the form.
 
1.  What type of feedback would you like to give us?
 
 
2.  Enter your feedback below: *
 
 
3.  Please provide us with your contact information:
 
Name: *
Company:
Country: *
Phone:
Email: *
Web Site:
 
4.  How would you like to be contacted?
 
No ContactBy MailBy FaxBy EmailBy Phone