Date
MM
DD
YYYY
What is your Zip Code?
*
What county do you live in?
*
Are you homeless?
*
Select
Yes
No
Other
Household Income
*
What is the primary language used in the home?
*
Select
English
Spanish
Hmong
American Sign Language
Other
Prefer not to say
Gender
*
Select
Male
Female
Transgender
Non-binary/Genderfluid/Prefer to self-describe
Prefer not to say
Age
*
Select
Under 18
18-24
25-34
35-44
45-54
55-64
65-74
75-84
85-94
95 & Over
Prefer not to say
How would you describe yourself?
*
Select
African American / Black
Asian
Caucasian / White
Hispanic / Latino
Middle Eastern
Multi-racial
Native American
Native Hawaiian / Pacific Islander
Other
Prefer not to say
Are you or have you ever been a member of the Armed Forces?
*
Select
Yes
No
Prefer not to say
Gender
Select
Male
Female
Transgender
Non-binary/Genderfluid/Prefer to self-describe
Prefer not to say
Age
Select
Under 18
Age 18-24
Age 25-34
Age 35-44
Age 45-54
Age 55-64
Age 65-74
Age 75-84
Age 85-94
Age 95 & Older
Prefer not to say
How would you describe yourself?
Select
African American/Black
Asian
Caucasian/White
Hispanic/Latino
Middle Eastern
Multi-racial
Native American
Native Hawaiian/Pacific Islander
Other
Prefer not to say
Are you or have you ever been a member of the Armed Forces?
Select
Yes
No
Prefer not to say
Gender
*
Select
Male
Female
Transgender
Non-binary/Genderfluid/Prefer to self-describe
Prefer not to say
Age
*
Select
Age 0-3
Age 4-5
Age 6-11
Age 12-17
How would they describe themselves?
*
Select
African American/Black
Asian
Caucasian/White
Hispanic/Latino
Middle Eastern
Multi-racial
Native American
Native Hawaiian/Pacific Islander
Other
Prefer not to say
How many male siblings?
*
How many female siblings?
*
