Household Grocery Survey Form

Full Name*

Email*

City & Province*

Phone Number*

How many members are in your household?* Adults: Children (under 18):

Are there any food preferences (or restrictions) in your house? (Check all that apply)*
Vegetarian  Vegan  Gluten-free  Dairy-free  Nut-free  Kosher  Halal  Other (please specify) 

What are your top three grocery stores or platforms? a.
b.
c.

How often do you shop for groceries?*
Daily  Weekly  Bi-weekly  Monthly  Other (please specify): 

Do you currently use a grocery delivery or subscription service?*
Yes NO

Pool Now