survey form sample (for investigatory project)

Rogationist College
High School Department
S. Y. 2007 – 2008


We Lei Demillo, Kim Jitsukawa, Gerard Mendoza, Edward Roberto, Raphael Buscayno, of III-St. Joseph, are currently conducting a research entitled “POTASSIUM OR SODIUM HYDROXIDE (LYE) FROM URAY PLANT (PIGWEED)”. In line with this, we are gathering data through this questionnaire as part of the requirements in chemistry.

Name(optional): ______________________
Yr.§ion : ______________________

(please put check mark on your answer)
Legend: a- agree
b- disagree


1. Do you agree that lye (sodium hydroxide) can be use as food additive to be used in preparing some native dishes like kutsinta?
A B
( ) ( )
2. Do you agree that lye can be used as the add color to other foods? (a) (b)
3. Do you agree that plants such as weeds can also be useful if they wise given importance and value?
(a) (b)
4. Do you agree that added with sodium hydroxide/ lye has a delicious taste which can be appetizing?
(a) (b)
5. Do you agree that uray plant/ pigweed can be a source of sodium potassium hydroxide or lye, “lihiya” in Filipino?
(a) (b)
6. Do you agree that people can prepare foods without commercial sodium hydroxide or lye but using the available plant in the surroundings?
(a) (b)