No, but I would start off with a basic HTML form like such:
<form name='example' action='submit.php' method='post'>
How would you rate the following? Select 1-5 for each.<br/>
HTML: <select name='HTML'>
<option>1</option>
<option>2</option>
<option>3</option>
<option>4</option>
<option>5</option>
</select><br/>
JavaScript: <select name='JS'>
<option>1</option>
<option>2</option>
<option>3</option>
<option>4</option>
<option>5</option>
</select><br/>
PHP: <select name='PHP'>
<option>1</option>
<option>2</option>
<option>3</option>
<option>4</option>
<option>5</option>
</select><br/>
ASP: <select name='ASP'>
<option>1</option>
<option>2</option>
<option>3</option>
<option>4</option>
<option>5</option>
</select><br/>
</form>
Once you have that, go to W3Schools and learn some JavaScript to validate the users selections. Then you can write a PHP (I recommend it) file to tally the selections and place them in a MySQL Table for result viewing.