\documentclass[12pt]{article}

\usepackage{pstricks}
\usepackage{amsmath,amsfonts,tikz}

% Put these before fancyhdr lest the headers and footers be the wrong length.
\textwidth = 6.5in   % 1in margins all around.
\hoffset = 0in       % These keep left margins at 1in.
\oddsidemargin = 0in
% So that there is one-half inch at top and bottom.
% See Math Into LaTeX, p. 260.
\topmargin = 0pt
\voffset = -0.5in
\textheight = 8.85in

\usepackage{fancyhdr}
\pagestyle{fancy}

\lhead{Name:}
\chead{}
\rhead{28 September 2016}
\lfoot{}
\cfoot{}
%\rfoot{12 September 2016}

\renewcommand{\headrulewidth}{0pt}

\def\dint{\displaystyle\int}

\parskip=\bigskipamount
\parindent=0pt

\def\banner#1{\hrule\begin{center}{\sc #1}\end{center}\bigskip\hrule}

\def\reals{{\mathbb R}}
\def\nat{{\mathbb N}}

\def\pvec#1#2{\left(\begin{matrix}#1\cr#2\end{matrix}\right)}
\def\pvectd#1#2#3{\left(\begin{matrix}#1\cr#2\cr#3\end{matrix}\right)}
\def\bmatrix#1#2#3#4{
\left[\begin{matrix}#1&#2\cr #3&#4\end{matrix}\right]
}
\def\bmatrixtd#1#2#3#4#5#6#7#8#9{
\left[\begin{matrix}#1&#2&#3\cr #4&#5&#6\cr#7&#8&#9\end{matrix}\right]
}


\begin{document}

\def\myform{
Presenter:

The presenter was well-prepared (5 is the best):
$$\hskip1in 1 \hskip1in 2 \hskip1in 3 \hskip1in 4 \hskip1in 5$$
The presentation was clear (5 is the best):
$$\hskip1in 1 \hskip1in 2 \hskip1in 3 \hskip1in 4 \hskip1in 5$$
I want to learn more about the topic after the presentation (5 is the best):
$$\hskip1in 1 \hskip1in 2 \hskip1in 3 \hskip1in 4 \hskip1in 5$$

What do you think is the speaker's biggest strength?
\vskip 0.75in

What is one way the speaker could improve?
\vskip 0.75in

}

\myform 

\myform

\eject

\myform 

\myform
\end{document}

