[splish]

The site provides no useful information for people who are entering information of suspect reliability.

Your user is faced with nothing of value other than your assurance (in repeated caps) that things should remain anonymous.

Why not give a better picture of what on earth is going on, otherwise it's just a form to submit some numbers, and an email.

[portmanteaufu]

"City, State, Country" doesn't work well for those folks not residing in the USA. Perhaps you could rephrase it?

"What industry" might also be rather unclear. What if I'm writing a web page for Exxon? Is my industry "Software Development?" "Web Development?" "Oil?"