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2. 

3. Goochland County wants to hear from you. Please submit your feedback by filling out the below information. Please provide your information if you would like us to contact you (optional).

5. First Name
6. Last Name
8. Email if you would like us to contact you
9. Phone number if you would like us to contact you

11. Please rate the below items based on your experience.

13. Department Visited
15. Quality of the Service Received
    -- Select One --12345

    5 = Excellent   1 = Poor

    
    

16. Helpfulness of County Staff
    -- Select One --12345

    5 = Excellent   1 = Poor

18. Knowledge/Expertise of County Staff
    -- Select One --12345

    5 = Excellent   1 = Poor

    
    

19. Overall Experience
    -- Select One --12345

    5 = Excellent   1 = Poor

    
    

21. Let us know about your experience.
23. Permission

    Goochland County has my permission to publicly share my survey responses and/or comments, either as quotations, paraphrased, or summarized, so long as I am identified by no more than my initials, first name, or first name and initial of last name.  I understand that Goochland County may use my responses and/or comments in reports, presentations, publications, websites and social media.

24. Yes or No*
    -- Select One --YesNo
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26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field