While much of what you are going to read from me is the same from other users, perhaps my opinion will help in that it's simply an additional opinion. My first

While much of what you are going to read from me is the same from other users, perhaps my opinion will help in that it's simply an additional opinion. My first impression is that the design will need to be redone. As someone mentioned, you've got something prototype-worthy, but it will need to be significantly beefed up before it is shown to customers. If you can't do it, get a designer on board. My second impression is that this is wufoo. I'm not sure exactly what you are offering that Wufoo or Google Docs doesn't already offer besides sharing a widget instead of a link. Have you surveyed customers to determine if they would respond better to a graphical survey (like a widget) versus a link to a survey? I'm not sure a widget would lower the barrier of entry enough for me to increase my desire to fill out a survey. Finally, I agree you will need a copywriter/editor to clean up the text. Capitalizations are weird or explanations are a bit confusing. Cleaning up the copy will help significantly. Best of luck!