Provide more clarity around the rows viz
Is the user supposed to enter his email ?
Whats the second row meant for ?
You echo what I was wondering. There are no identifiers on the boxes so how would a user know what to input? Keep in mind that just because you know what they are used for doesn't mean that a visitor to your site will.
While having the ability to offer feedback will be used by some customers, I am in agreement with Stiljoor in that most just won't take the time.
Perhaps having selections available, in addition to the user input, might (I stress "might") have more success?
For example:
Reason you use our service:
Price
Ease of use
Peace of mind
Other - (Input box so they can list reason not included above)
Would you recommend our service:
Yes
No
If No -(Input box for reason)
Etc. etc. etc.
A few radio buttons for the choices and you have at least made the feedback a bit more painless and less time consuming. A user simply clicks a few times and submits. You may find that you get more results this way. And by including input boxes for questions that the reason may not be on list you give them the ability to submit it. So you retain the user input as well as give specific choices, thereby decreasing time needed and hopefully resulting in people taking 10 secs to click the reasons and submit.
