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: *
Country: *
Email: *
Web Site:
4.  How would you like to be contacted?
No ContactBy MailBy FaxBy EmailBy Phone