<link href="//netdna.bootstrapcdn.com/bootstrap/3.0.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css"> <script src="//netdna.bootstrapcdn.com/bootstrap/3.0.0/js/bootstrap.min.js"></script> <script src="//code.jquery.com/jquery-1.11.1.min.js"></script> <!------ Include the above in your HEAD tag ----------> <div class="container"> <form class="form-horizontal"> <fieldset> <!-- Form Name --> <legend>Satisfaction Survey of GET WIRELESS Partnership Channel – 2015</legend> <!-- Multiple Radios (inline) --> <div class="control-group"> <label class="control-label" for="question1">1.As a partner, what’s your level of satisfaction during your cooperation with GET WIRELESS? </label> <div class="controls"> <label class="radio inline" for="question1-0"> <input name="question1" id="question1-0" value="Very satisfied" checked="checked" type="radio"> Very satisfied </label> <label class="radio inline" for="question1-1"> <input name="question1" id="question1-1" value="Satisfied" type="radio"> Satisfied </label> <label class="radio inline" for="question1-2"> <input name="question1" id="question1-2" value="Not really satisfied" type="radio"> Not really satisfied </label> <label class="radio inline" for="question1-3"> <input name="question1" id="question1-3" value="Insatified" type="radio"> Insatified </label> </div> </div> <!-- Textarea --> <div class="control-group"> <label class="control-label" for="question2">2.Which reasons you are not totaly satisfied, or insatisfied about your cooperation with GET WIRELESS?</label> <div class="controls"> <textarea id="question2" name="question2"></textarea> </div> </div> <!-- Multiple Radios --> <div class="control-group"> <label class="control-label" for="question3">3.On average, how often are you in contact with GET Wireless ?</label> <div class="controls"> <label class="radio" for="question3-0"> <input name="question3" id="question3-0" value="One time per week" checked="checked" type="radio"> One time per week </label> <label class="radio" for="question3-1"> <input name="question3" id="question3-1" value="Several Time a month" type="radio"> Several Time a month </label> <label class="radio" for="question3-2"> <input name="question3" id="question3-2" value="About once a month" type="radio"> About once a month </label> <label class="radio" for="question3-3"> <input name="question3" id="question3-3" value="Every two or three times per" type="radio"> Every two or three times per </label> <label class="radio" for="question3-4"> <input name="question3" id="question3-4" value="month" type="radio"> month </label> <label class="radio" for="question3-5"> <input name="question3" id="question3-5" value="Less often" type="radio"> Less often </label> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="question4">4.Thank you to indicate the last date of contact with GET WIRELESS.</label> <div class="controls"> <input id="question4" name="question4" placeholder="" class="input-xlarge" required="" type="text"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="question5">5.How often are you contacting GET WIRELESS throw the following means?</label> </div> <!-- Multiple Radios (inline) --> <div class="control-group"> <label class="control-label" for="question51">By téléphone</label> <div class="controls"> <label class="radio inline" for="question51-0"> <input name="question51" id="question51-0" value="Always" checked="checked" type="radio"> Always </label> <label class="radio inline" for="question51-1"> <input name="question51" id="question51-1" value="Often" type="radio"> Often </label> <label class="radio inline" for="question51-2"> <input name="question51" id="question51-2" value="scarcely" type="radio"> scarcely </label> <label class="radio inline" for="question51-3"> <input name="question51" id="question51-3" value="Never" type="radio"> Never </label> </div> </div> <!-- Multiple Radios (inline) --> <div class="control-group"> <label class="control-label" for="question52">By email</label> <div class="controls"> <label class="radio inline" for="question52-0"> <input name="question52" id="question52-0" value="Always" checked="checked" type="radio"> Always </label> <label class="radio inline" for="question52-1"> <input name="question52" id="question52-1" value="Often" type="radio"> Often </label> <label class="radio inline" for="question52-2"> <input name="question52" id="question52-2" value="scarcely" type="radio"> scarcely </label> <label class="radio inline" for="question52-3"> <input name="question52" id="question52-3" value="Never" type="radio"> Never </label> </div> </div> <!-- Multiple Radios (inline) --> <div class="control-group"> <label class="control-label" for="question53">face-à-face (Workshop, Meeting)</label> <div class="controls"> <label class="radio inline" for="question53-0"> <input name="question53" id="question53-0" value="Always" checked="checked" type="radio"> Always </label> <label class="radio inline" for="question53-1"> <input name="question53" id="question53-1" value="Often" type="radio"> Often </label> <label class="radio inline" for="question53-2"> <input name="question53" id="question53-2" value="scarcely" type="radio"> scarcely </label> <label class="radio inline" for="question53-3"> <input name="question53" id="question53-3" value="Never" type="radio"> Never </label> </div> </div> <!-- Multiple Radios (inline) --> <div class="control-group"> <label class="control-label" for="question6">6.Your global perception about GET WIRELES</label> <div class="controls"> <label class="radio inline" for="question6-0"> <input name="question6" id="question6-0" value="Very satisfied" checked="checked" type="radio"> Very satisfied </label> <label class="radio inline" for="question6-1"> <input name="question6" id="question6-1" value="Satisfied" type="radio"> Satisfied </label> <label class="radio inline" for="question6-2"> <input name="question6" id="question6-2" value="Insatisfied" type="radio"> Insatisfied </label> <label class="radio inline" for="question6-3"> <input name="question6" id="question6-3" value="totaly Insatisfait" type="radio"> totaly Insatisfait </label> </div> </div> <!-- Multiple Radios --> <div class="control-group"> <label class="control-label" for="question61">The summary monthly reports are regulary transmitted?</label> <div class="controls"> <label class="radio" for="question61-0"> <input name="question61" id="question61-0" value="Yes, regulary" checked="checked" type="radio"> Yes, regulary </label> <label class="radio" for="question61-1"> <input name="question61" id="question61-1" value="Yes, but not every month" type="radio"> Yes, but not every month </label> <label class="radio" for="question61-2"> <input name="question61" id="question61-2" value="Just after request" type="radio"> Just after request </label> <label class="radio" for="question61-3"> <input name="question61" id="question61-3" value="No, any activity report is received since 2014" type="radio"> No, any activity report is received since 2014 </label> </div> </div> <!-- Textarea --> <div class="control-group"> <label class="control-label" for="question62">Else, thank you to indicate the relatif project:</label> <div class="controls"> <textarea id="question62" name="question62"></textarea> </div> </div> <!-- Multiple Radios (inline) --> <div class="control-group"> <label class="control-label" for="question7">7.Number of Workshop in Tunisia and Algeria</label> <div class="controls"> <label class="radio inline" for="question7-0"> <input name="question7" id="question7-0" value="One time per year" checked="checked" type="radio"> One time per year </label> <label class="radio inline" for="question7-1"> <input name="question7" id="question7-1" value="two times per year" type="radio"> two times per year </label> <label class="radio inline" for="question7-2"> <input name="question7" id="question7-2" value="One time every two years" type="radio"> One time every two years </label> </div> </div> <!-- Multiple Radios (inline) --> <div class="control-group"> <label class="control-label" for="question8">8.Le suivi est opportunités en cours est :</label> <div class="controls"> <label class="radio inline" for="question8-0"> <input name="question8" id="question8-0" value="Bad" checked="checked" type="radio"> Bad </label> <label class="radio inline" for="question8-1"> <input name="question8" id="question8-1" value="Medium" type="radio"> Medium </label> <label class="radio inline" for="question8-2"> <input name="question8" id="question8-2" value="Good" type="radio"> Good </label> <label class="radio inline" for="question8-3"> <input name="question8" id="question8-3" value="Excellent" type="radio"> Excellent </label> </div> </div> <!-- Multiple Radios (inline) --> <div class="control-group"> <label class="control-label" for="question9">9.Intervention deadline of GET WIRELESS team if necessary</label> <div class="controls"> <label class="radio inline" for="question9-0"> <input name="question9" id="question9-0" value="Bad" checked="checked" type="radio"> Bad </label> <label class="radio inline" for="question9-1"> <input name="question9" id="question9-1" value="Medium" type="radio"> Medium </label> <label class="radio inline" for="question9-2"> <input name="question9" id="question9-2" value="Good" type="radio"> Good </label> <label class="radio inline" for="question9-3"> <input name="question9" id="question9-3" value="Excellent" type="radio"> Excellent </label> </div> </div> <!-- Multiple Radios (inline) --> <div class="control-group"> <label class="control-label" for="question10">10.The contact in GET WIRELESS is friendly</label> <div class="controls"> <label class="radio inline" for="question10-0"> <input name="question10" id="question10-0" value="Totaly agree" checked="checked" type="radio"> Totaly agree </label> <label class="radio inline" for="question10-1"> <input name="question10" id="question10-1" value="agree" type="radio"> agree </label> <label class="radio inline" for="question10-2"> <input name="question10" id="question10-2" value="disagree" type="radio"> disagree </label> <label class="radio inline" for="question10-3"> <input name="question10" id="question10-3" value="totaly disagree" type="radio"> totaly disagree </label> </div> </div> <!-- Multiple Radios (inline) --> <div class="control-group"> <label class="control-label" for="question11">11.The contact in GET WIRELESS has a positive attitude</label> <div class="controls"> <label class="radio inline" for="question11-0"> <input name="question11" id="question11-0" value="Totaly agree" checked="checked" type="radio"> Totaly agree </label> <label class="radio inline" for="question11-1"> <input name="question11" id="question11-1" value="agree" type="radio"> agree </label> <label class="radio inline" for="question11-2"> <input name="question11" id="question11-2" value="disagree" type="radio"> disagree </label> <label class="radio inline" for="question11-3"> <input name="question11" id="question11-3" value="totaly disagree" type="radio"> totaly disagree </label> </div> </div> <!-- Multiple Radios (inline) --> <div class="control-group"> <label class="control-label" for="question12">12.Our period of reaction is :</label> <div class="controls"> <label class="radio inline" for="question12-0"> <input name="question12" id="question12-0" value="Too slow" checked="checked" type="radio"> Too slow </label> <label class="radio inline" for="question12-1"> <input name="question12" id="question12-1" value="Enough" type="radio"> Enough </label> <label class="radio inline" for="question12-2"> <input name="question12" id="question12-2" value="Variable" type="radio"> Variable </label> <label class="radio inline" for="question12-3"> <input name="question12" id="question12-3" value="Good" type="radio"> Good </label> </div> </div> </fieldset> </form> </div>