This form was designed with my current fifth grade placement class in mind. They are in the middle of a literature circles unit and are reading a variety of books in small groups. Since reading groups provide an opportunity for diversification of instruction they are something that I hope to include in my own class one day, and something I could create using this Google form.
The goal of this form is to help me understand what kind of readers my students are in order to help better place them with readers that are at a similar level and have similar interests. The students would fill out this form as an introduction to the unit, and I could then use their responses to create appropriate reading groups for the students that best address the needs expressed in the survey. Having all of this information in a digital format makes it easy for the teacher to keep track of, and even refer back to at the end of the unit, seeing areas where the students may have shown improvement by the end of their reading circle. The students could fill out this form in a variety of ways: it could be assigned as homework, thus allowing the students to respond on their own devices at home, or it could be done in class in either a one-to-one environment, or on a classroom computer which the students could take turn using.