(Edit: In hindsight I designed this survey poorly. Most of us assign points ahead of time for each question and then tally it up. I've changed the setup to reflect that so you only see the content and format first and then the results later. I'll mark on the spreadsheet where I made the change.)
You can use any criteria or scoring system you like.
The first three sections are testing content and/or skills that have been directly taught and are similar to something a student could find in notes, exercises in the book, homework, and classwork.
The essay is asking for a novel application of the content or skills that were directly taught. The question/answer would not be found in the textbook or notes but could be answered given sufficient mastery of the course material.
I realize this isn't a math-friendly format but if you're a math teacher, pretend 1,2 are the easy questions on a test. 3 are the harder ones. For 4, think "problem", not "exercise."
I've seen something like this in books and various conference sessions and have been wanting to try it. Don't leave any comments about your score just yet. I'll post results in a few weeks and hope to include it in a presentation for my staff. I have no idea if you can see the form at the bottom in a feed reader or on a mobile device. Sorry in advance. Thanks for the help.