Citizen Survey Information Collection Form

Citizen Survey Information Collection Form
Please provide your feedback and information to help improve our community. Your responses are valuable and will remain confidential.
Full Name
First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Age Group
Gender
Other
Highest Level of Education Completed

How satisfied are you with the following community services?

Rows	Very Satisfied	Satisfied	Neutral	Dissatisfied	Very Dissatisfied
Public Transportation
Public Safety/Police
Sanitation & Waste Management
Parks and Recreation
Local Healthcare Services

How often do you participate in community activities or events?
Please rate your overall satisfaction with your local government.
What are the most important issues facing your community? (Select up to 3)
Other
How would you rate your sense of safety in your neighborhood?

1
2
3
4
5
1 is Very Unsafe, 5 is Very Safe
Please provide any additional comments or suggestions to help improve your community.
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