Research methods exercise - design a survey form

Identify a research question that you are interested in.
You need to follow the following design principles of survey:
a. Keep it short
b. Clear questions
c. Give instructions and examples
d. May use scales

Ensure you have the following variables
1. Response variable (to be used as variable y in regression analysis)
2. Independent variable (to be used as variable x's in regression analysis)
3. Control variables: not directly related to the research question (to be used as variable x's in regression analysis)
3.1 endogenous to the client system(s) studied (e.g. a company)
3.2 exogenous


Reference
Adams, J. et al. 2007. "Chapter 8: Surveys" Research Methods for Graduate Business and Social Science students, SAGE, Los Angeles.