Sample Questionnaire

Directions: Please share with us your vision of our community 20 years from now. Please give only one response per line, in no particular order. Continue on the back of this sheet if more space is needed. Thank you for your participation!

Example: Children will be taught to make smart decisions regarding the value and use of money.
Example: The river will be clean enough that we may eat fish caught from it.
Example: Our community will have more locally owned businesses.

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Please provide the following information about yourself to assist us in analyzing the responses.

___Male ___Female What is your annual income?
___ under $20,000 ___ $21,000 to $40,000
Age: ___ $41,000 to 60,000 ___ $61,000 to $80,000
___under 20 ___21-30 ___ over $80,000

___31-40

 ___41-50
___51-65 ___over 65
Thank you for completing this questionnaire!
How many people live in your household?
___ 1 - 2 ___3 - 4
Please return by [insert deadline date] to:
___ 5 - 8 ___9 - 12
___ more than 12
[insert return address here]
Of what ethnicity are you?___________________