Why make it so formal? Teachers would rather tell you verbally than have to fill out a form.
Either ask your principal to attend the next staff meeting and ask them in person or just put a poster in the teachers lounge and have them write comments on it.
Our PTO has an Arts in Education Committee. We sometimes have in-school events for the students as a complement to the school curriculum. We would like to send a survey out to the teachers to find out if the feel the last event was worth the time and money. Does anyone have a form like this that we could use as a way to get started?