\documentstyle{report}

\pagestyle{myheadings}
\def\headlineaux{\sc Math 220/317: Programming II/Data Structures 
\hrulefill
}
\markboth{\headlineaux}{\headlineaux}

\setlength{\textwidth}{6.25in}
\setlength{\oddsidemargin}{0in}
\setlength{\evensidemargin}{0in}

\begin{document}

\begin{titlepage}
Blank Page
\end{titlepage}

\subsection*{Questionnaire\hfill\today}

The information on this questionnaire will be used to create
an account for you and to help me focus the level
of classroom discussion.
\begin{enumerate}
\item Your First Name:
\bigskip
\item Your Middle Name:
\bigskip
\item Your Last Name:
\bigskip
\item Your Student ID:
\bigskip
\item Math courses you have taken:
\bigskip
\bigskip
\bigskip
\bigskip
\item Computer courses you have taken:
\bigskip
\bigskip
\bigskip
\bigskip
\item Computer programming you have done:
\bigskip
\end{enumerate}


\end{document}
