Inspired by Malcolm X Survey

Background

1. What is your gender?
Female
Male

2. How old are you?
        under 13
        13-17
        18-21
        22-25
        26-30
        30+

3. What is your ethnicity?
        White
        African American
        American
        Hispanic
        Caucasian
        Latino
        Other

4. If other, please specify.

5. What is your religion?
        Catholic
        Baptist
        Lutheran
        Muslim
        No religion
        Other

6. If other, please specify.

7. Are you...?
        Homosexual
        Heterosexual
        Bisexual
        Other

8. If other, please specify.

9. Where did you spend most of your life growing up?
        In a city
        In the suburbs of a city
        In the country
        Other

10. If other, please specify

11. Are your parents...?
        Racist completely
        Racist a little (will let you have friends of another color but will not let you date people of another color)
        Not racist at all
        I do not know