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Region 1 Community Transportation Survey
For the counties of Joe Daviess, Carroll, Stephenson, Winnebago, and Boone
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* Indicates required question
Date:
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MM
/
DD
/
YYYY
County name:
*
Your answer
Do you or members of your household have access to (and can afford) a car or other vehicle that is running, licensed, and insured?
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Yes
No
Are there trips you or members of your household can't make because of a lack of transportation?
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Yes
No
If yes, what kind of trips: (Check all that apply)
Work
Medical appointments
Visiting friends or family
Shopping
Social / Entertainment
School
Kids activities (pool, park, skating, etc.)
Senior nutrition or day center
Religious
Other Agency Appointments
N/A
Other:
How do you or members of your household travel now? (check all that apply)
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Drive or ride in household member's vehicle
Drive or ride in someone else's vehicle (other than a household member's)
Walk, bike, use wheelchair, etc.
Church or social service agency vehicle
Public transportation
N/A
Other:
Required
Do you or members of your household currently use public transportation?
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Yes
No
If yes, what types of transportation do you or members of your household use? (check all that apply)
Bus
Taxi
Van
N/A
Other:
Would you or members of your household use public transportation if it was available?
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Yes
No
If available, what types of transportation would you or members of your household use? (Check all that apply)
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Bus
Taxi
Van
N/A
Other:
Required
If available, how would you or members of your household prefer to get a ride? (check all that apply)
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Catch a bus at a bus stop
Call ahead for a ride (curb-to-curb demand response service)
Call ahead for a ride (door-to-door demand response service for seniors or people with disabillities
N/A
Other:
Required
Please list locations (city/town names) that you or members of your household would travel to using public transportation. Write N/A if not applicable.
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Your answer
Using public transportation, how often would you or members of your household travel to the communities listed above? (Circle all that apply)
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Daily
Weekly
Monthly
N/A
What times would you or members of your household need public transportation? (check all that apply)
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Weekdays, before 7:00 AM
Weekdays , 7:00 AM to 5:00 PM
Weekdays, 5:00 PM to 10:00 PM
Weekdays, after 10:00 PM
Weekends, 7:00 AM to 5:00 PM
Weekends, 5:00 PM to 10:00 PM
Weekends, other times
Holidays
N/A
Required
How much would you or members of your household be willing to pay for a one-way trip within your county? (choose one)
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Less than $1.00
$1.00
$2.00
$3.00
$4.00
$5.00
$6.00 or more
N/A
Required
What would you change about your household's experience with public transportation and why? Write N/A if not applicable.
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Your answer
Demographics
What is your zip code?
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Your answer
In what age range do you belong? (Circle one)
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under 20
20 - 29
30 - 39
40 - 49
50 -- 59
60 - 69
70 - 79
80 and over
How many people live in your household? (choose one)
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1
2
3
4+
Required
Does anyone in your household have a disability (physical, mental, etc.) which limits the ability to drive?
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Yes
No
If yes, how many people? Write N/A if not applicable.
Your answer
Do any of your household members need transportation to medical appointments outside the county?
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Yes
No
If yes, what city / county? Write N/A if not applicable.
Your answer
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