Customer Complaint Form Template

<form action="https://splitforms.com/api/submit" method="POST" enctype="multipart/form-data">
  <input type="hidden" name="access_key" value="YOUR_ACCESS_KEY">
  <input type="hidden" name="subject" value="New customer complaint">
  <input type="hidden" name="form_loaded_at" id="form_loaded_at">

  <fieldset>
    <legend>1. About you</legend>
    <label>Full name <input type="text" name="name" autocomplete="name" required></label>
    <label>Email <input type="email" name="email" autocomplete="email" required></label>
    <label>Phone (optional) <input type="tel" name="phone" autocomplete="tel"></label>
    <label>How should we reply?
      <select name="preferred_contact">
        <option>Email</option>
        <option>Phone call</option>
      </select>
    </label>
  </fieldset>

  <fieldset>
    <legend>2. What happened</legend>
    <label>Order, booking or account number (if you have one)
      <input type="text" name="reference">
    </label>
    <label>Date it happened <input type="date" name="incident_date" required></label>
    <label>What is the complaint about?
      <select name="category" required>
        <option value="">Choose one</option>
        <option>Product</option>
        <option>Service or workmanship</option>
        <option>Billing or charges</option>
        <option>Delivery</option>
        <option>A member of staff</option>
        <option>Website or app</option>
        <option>Something else</option>
      </select>
    </label>
    <label>Location, branch or page (optional)
      <input type="text" name="location">
    </label>
    <label>Tell us what happened, in order
      <textarea name="description" rows="6" required></textarea>
    </label>
  </fieldset>

  <fieldset>
    <legend>3. Putting it right</legend>
    <label>What would resolve this for you?
      <select name="resolution_wanted" required>
        <option value="">Choose one</option>
        <option>Refund</option>
        <option>Replacement or repair</option>
        <option>Redo the service</option>
        <option>Correct a billing error</option>
        <option>An explanation or apology</option>
        <option>Something else (say above)</option>
      </select>
    </label>
    <label>Have you already contacted us about this?
      <select name="previous_contact" required>
        <option value="">Choose one</option>
        <option>No, this is the first time</option>
        <option>Yes, and it is not resolved</option>
      </select>
    </label>
    <fieldset>
      <legend>Is anyone's safety at risk?</legend>
      <label><input type="radio" name="safety_risk" value="no" required> No</label>
      <label><input type="radio" name="safety_risk" value="yes"> Yes</label>
    </fieldset>
  </fieldset>

  <fieldset>
    <legend>4. Evidence (optional)</legend>
    <!-- File uploads are stored on paid plans -->
    <label>Photo, receipt or screenshot
      <input type="file" name="evidence" accept=".pdf,.jpg,.jpeg,.png">
    </label>
  </fieldset>

  <!-- honeypot: leave empty -->
  <input type="checkbox" name="botcheck" style="display:none" tabindex="-1" autocomplete="off">

  <button type="submit">Send complaint</button>
</form>
<script>
  document.getElementById('form_loaded_at').value = Date.now();
</script>