Dear Dixita,
Nice format. However, an employee, while leaving, will not necessarily give you the actual reasons for leaving to avoid any unpleasantness. So, the best way to get good feedback is to make the format more objective, and the identity of the employee should be kept confidential. The name, designation, all these things should be optional and not compulsory. Employees may be asked to write the total duration of tenure and not necessarily the date of joining/leaving.
These forms should be issued at least three days before leaving the organization, and the employee can drop the duly filled exit interview form in a suggestion box. The suggestion box should be opened only once a month in the presence of two to three people from other departments.
This way, without fear of disclosing identity, employees will give real feedback.
Thanks and Regards,
Bahubali