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Community Input Survey
1.
What is your zip code?
2.
Please choose your age group:
31-40
41-50
51-60
61-70
71-80
Over 80
3.
How often do you eat at a Meals on Wheels People dining site?
Never
1 to 2 times a week
3 or more times a week
4.
How often do you go out to eat at a restaurant?
Never
1 to 2 times a week
3 or more times a week
5.
What meal do you most often eat at restaurants (choose one only)?
breakfast
lunch
dinner
coffee or snacks
6.
How far do you live from a Meals on Wheels People dining site?
1 to 5 miles
6 to 10 miles
11 to 15 miles
More than 15 miles
7.
How far do you usually travel to eat at restaurants?
1 to 5 miles
6 to 10 miles
11 to 15 miles
More than 15 miles
8.
Would you attend a restaurant that was open to the public, which also provided a senior specific donation-based healthy meal option?
Yes
No
9.
What type of service would you prefer (choose one)?
Senior Center Dining Room
Café or Restaurant
Take-Out
Other (please specify)
