What we will ask

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

What we will ask

The Appomattox Library wants to preserve this moment of history by asking our patrons to take a minute and reflect on their experiences during this public health crisis. We would like for you to share these reflections and stories with us. The purpose of this project is to share our experiences and have it for future generations. We want to guard your privacy, but we would like for you to share your names with us as it adds a personal nature and allows for greater connection. If you prefer you can select having just your first name shared.

What is your Name: *

How would you like us to share your name? *

You can use my name

You can use just my first name

I would like to remain Anonymous

Where do you live? *

City of Colonial Heights

City of Hopewell

City of Petersburg

Chesterfield County

Dinwiddie County

Prince George County

Richmond

Other:

What is your age range? *

12 or younger

13-17

18-28

29-38

39-48

49-58

59-68

69-78

79+

May we contact you for followup questions? *

Yes

Clear form

Never submit passwords through Google Forms.

This form was created inside of Appomattox Regional Library System. Report Abuse

Forms