Carmen De La Rosa for City Council Community Survey

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This survey is for residents and businesses of the 10th City Council District.

As Carmen begins her transition to City Hall in January 2022, she wants to hear from you!

The needs and vision of the community are essential as she further develops her priorities in the next City Council.

***We collect certain demographic information to understand who is completing our survey as part of our work to deliver inclusive programs that appeal to everyone in our community. Only intake staff can see this information***

First Name *

Last Name *

Email *

What Neighborhood Do You Live/Work In? *

Gender

Preferred Pronouns

Race-Ethnicity(ies). Select all that apply.

American Indian or Alaska Native

Asian or Asian American

Black or African American

Hispanic, Latino, Latina, or Latinx

Middle Eastern or Northern African

Native Hawaiian or Other Pacific Islander

White

I prefer not to answer this question

Other:

Household Income

Less than $20,000

$20,000 to $34,999

$35,000 to $49,999

$50,000 to $74,999

$75,000 to $99,999

Over $100,000

Clear selection

Age

Under 18

18-24 years old

25-34 years old

35-44 years old

45-54 years old

55-64 years old

65-74 years old

75 and above

Clear selection

Clear form

Never submit passwords through Google Forms.

This form was created inside of Carmen for Council.

Does this form look suspicious? Report

Forms