Create Intake Form

Paste or edit the form schema JSON below.

Form Schema (JSON)

{
  "name": "Community Intake Form",
  "description": "Tell us what you need. Your information is encrypted on your device.",
  "fields": [
    {
      "id": "name",
      "label": "Name",
      "type": "text",
      "required": true,
      "placeholder": "Your name"
    },
    {
      "id": "phone",
      "label": "Phone",
      "type": "text",
      "placeholder": "(555) 555-5555"
    },
    {
      "id": "address",
      "label": "Address",
      "type": "text",
      "placeholder": "Street address"
    },
    {
      "id": "need",
      "label": "What do you need?",
      "type": "select",
      "required": true,
      "options": [
        "Groceries",
        "Medicine",
        "Transportation",
        "Childcare",
        "Other"
      ]
    },
    {
      "id": "details",
      "label": "Details",
      "type": "textarea",
      "placeholder": "Anything else we should know?"
    },
    {
      "id": "contact_ok",
      "label": "OK to contact by phone?",
      "type": "checkbox"
    }
  ]
}