MK built this from scratch, using the Question field for many fields.

 

This uses mostly built-in fields, added a Comments field.

 

Built a new integration that specifies the fields on this form and as an email integration. Added a rule to the Submit button which triggers the data to be emailed to specified recipient.

 

The data stored into your console’s database can be reviewed by downloading a raw data file. A raw data file can be downloaded from individual campaigns or globally for all campaigns at once. 

Multiple Choice

Value 2a
Value 2b
Value 2c

Single Choice

Value 1a
Value 1b
Value 1c
State
A state is required
Email address
You must enter a valid email address
Phone number
People in your household