This feedback form collects information about a household's electricity consumption and asks questions to assess knowledge about energy conservation. It collects the household service connection number, recent bi-monthly electricity consumption and billing amounts. It asks what energy conservation measures could be taken, expected savings, and contact information for queries. Multiple choice questions test knowledge about efficient bulbs, earth leakage circuit breakers, reducing usage, refrigerator usage, appliance star ratings, water heater types, sunny days in the city, bill payment methods, switching off appliances correctly, and the vision of "Powerful Kovai" as transforming Coimbatore into an energy conserved city.