The City of La Puente
Local Aging and Disability Action Plan Demographics Survey
Name
What is your age?
25 and under
26-35
36-45
46-55
56-65
66-75
76-85
Over 85
Prefer not to answer
How would you label your gender?
Male
Female
Prefer not to answer
Other
What is your racial/ethnic identity?
African American or Black
Asian or Asian American
Latino/Hispanic
American Indian or Alaska Native
Pacific Islander
White or Caucasian
Prefer not to answer
Other
How would you like to receive your $40 gift card?
Through Email or Mailing Address?
SUBMIT SURVEY
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