Here is a link to the simple form I created.
I have also embedded the form into the blog, using the embed code that is available from the More Actions options in Google Docs.
By the way, I found an example of an excellent way in which one school is using Google Forms to get feedback from students about books they would like to see the school library stock as well as other information. Once the forms are created, they are embedded right into a wiki where students can submit their replies. Check out this blog post about the project:
Community Conversations Using Google Forms, Docs, and Wiki to Connect Outside of Your School
|Image from: http://www.thedaringlibrarian.com/2010/09/community-conversations-using-google.html|