\documentclass{article}

\usepackage{pdfquiz}

\newcommand{\feedback}{\par%
   \edef\url{http://www.maths.bath.ac.uk/\string~masuh/cgi-bin/quiz.pl}
   \bgroup\parindent = 0pt\vbox{{\bf Feedback.}\par
   {\it Please enter your comments or questions below
      (only use when running inside a browser):}\newline
   \centerline{\qtext(.9\hsize,4cm)[comment]{Your comments.}}\par
   \hbox to \hsize{%
      {\it Name:}\space\underbar{\qline(.4\hsize)[name]{Your name.}}\hfill
      {\it Email:}\space\underbar{\qline(.4\hsize)[email]{Your email.}}%
      }\bigskip\leavevmode\hfill
   \qsend[\url:"name","email","comment"]{{\it Submit}}\par
   }\egroup}

\newcommand{\problem}{\underbar{\it Problem \the\qprbno.\/}\enspace}

\newcommand{\option}[1]{\ifcase#1%
   \qtick[1:correct;0:false]{$\bigcirc$}\or
   \qtick[0:false;1:correct]{$\bigcirc$}\fi}

\newcommand{\numopt}[1]{\ifcase#1%
   \qtick[1:good;-1:rubbish]{(\romannumeral\qoptno)}\or
   \qtick[-1:rubbish;1:good]{(\romannumeral\qoptno)}\fi}

\parindent = 0pt
\parskip = 1ex

\begin{document}

\title{Quiz}
\maketitle

This short quiz shall demonstrate the use of the primitive commands
$\backslash$qtext, $\backslash$qline, $\backslash$qsend (used here
to defined $\backslash$feedback) and of the four commands 
$\backslash$qtick, $\backslash$qnuml, $\backslash$qhint, $\backslash$qeval,
which are sufficient to produce a multiple choice quiz.

\problem Tick the correct statements.
\begin{itemize}
\item[\option1] This statement is true.
\item[\option1] This statement is false.
\item[\option0] This statement is true and false
   (\qhint[0.5:This is nonsense.]{\underbar{Hint}}).
\end{itemize}
\rightline{\qeval{\underbar{Evaluate}}}

\problem Tick statement number (ii).
\begin{itemize}
\item[\numopt0] This is statement \#\the\qoptno.
\item[\numopt1] This is statement \#\the\qoptno.
\item[\numopt0] This is statement \#\the\qoptno.
\end{itemize}
\rightline{\qeval{\underbar{Evaluate}}}

\problem Fill in numbers and tick the box.
\begin{itemize}
\item Fill in $1.3$:
   \underbar{\qnuml[1:correct;0:way off, should be 1.3]1.3(0.001)}.
\item Fill in $1.3$:
   \underbar{\qnuml[1:correct;0:way off, should be 1.3]1.3(0.000)}.
\item Fill in $3.1$:
   \underbar{\qnuml[1:correct;0:way off, should be 1.3]1.3(0.001)}
   and \qtick[0:false;1:correct]{tick here}.
\end{itemize}
\rightline{\qeval{\underbar{Evaluate}}}

\vskip 0.5em

\rightline{\qsave{\underbar{Save results}}}

\vskip 4em

\feedback

\end{document}

