JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Internet Access/Devices
The information being collected for data collection purposes only. Answers will not be used to determine eligibility.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Option 1
Clear selection
Are you filling this survey out for yourself or another in your household?
Self
Other:
Clear selection
First Name
*
Your answer
Last Name
*
Your answer
Address
*
Your answer
What is the best way to contact you?
*
Email
Phone Call
Phone Text
Mail
Other:
Email Address
Your answer
Phone Number
Your answer
How many devices (e.g., smart phones, computers, laptops, tablets) do you have in your household?
*
No devices
1 per household
1-2 per household
3-4 per household
4-5 per household
Other:
How do you currently access the internet?
*
No internet
Reliable high speed internet
Unreliable/Spotty internet
Mobile Hot Spot
Cellphone
Public Spaces (e.g., Library, Schools)
Business (e.g., Starbucks, Bexley Coffee House)
Other:
Would you be interested in speaking with someone who could help you access free/low-cost internet service?
*
Yes
No
What technology-related support might be helpful?
*
The only support I need is access. I am comfortable setting up my device
I need support setting up my device to the internet
I need support using my device to access the internet (e.g., email, websites, etc)
I need support in basic functions of my device (plugging in, turning on, etc)
Other:
Required
Race/Ethnicity
American Indian or Alaskan Native
Asian
Black/African American
Latinx/Hispanic
Native Hawaiian or Pacific Islander
White
Prefer not to reply
Other
Gender
Female
Male
Non-binary
Prefer not to reply
Clear selection
Age
0-18
18-64
65+
Prefer not to reply
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
