Very similar to the "Student Survey" that is a free download in my store.
This is a survey I give to my students on the first or second day of the Spanish 2 class. Some questions are in Spanish to start reviewing Spanish 1 material. Other, more complex questions are still in English. (I always tell them "if it's in Spanish, respond in Spanish; if it's in English, you can respond in English").
It helps me get to know them better and I do use their interests to drive some of my lesson plans.