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* 1. Are you currently able to drive?

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* 2. How frequently would you need transportation?

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* 3. If a transportation service became available in your community, to which of these destinations do you anticipate needing assistance? Check all that apply.

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* 4. What is your age?

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* 5. What is your home zip code?

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* 6. If you drive, to which of the following local destinations do you drive? Check all that apply.

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* 7. Are there any circumstances under which you would prefer not to drive? Check all that apply.

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* 8. During the past three months, which of the following factors prevented you from taking trips outside your home? Check all that apply.

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* 9. Over the past 3 months, how much did you rely on others for transportation?

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* 10. If you are willing to be a volunteer driver or dispatcher, please leave your contact information.

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* 11. If your place of worship or civic organization is interested in participating in this initiative, or if you would like more information, please leave your contact information.

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