First Day of Class Quiz

I've been toying around with an idea to overcome some of the hurdles discussed in this post. In particular, I want to change students' perception of what math is really about and the negative perception that they either are not good at math or cannot become good at math (obviously, I'm not talking about all students, since some don't have this problem).

My idea is to open up the class with a quiz. It's not so much a quiz as a self-assessment. I want to get them to start thinking differently from the beginning. My mind is geared right now towards my Elementary and Intermediate Algebra class (Math 097, Section 3). Here are some of the questions I want to ask (besides name, email, and those things):

1. Why are you taking this class?
2. What are the necessary skills required to be good at math?
   
3. What do you hope to gain from taking this class?
   
4. On a scale of 1-5 with 5 being "highly proficient", rate your mathematical ability.

I want to do a last day of class something where I give this back to them and have them evaluate the class. This is still a work in progress.