Municipal Pothole Reporting and Road Feedback Form

Municipal Pothole Reporting and Road Feedback Form — Form Fields

This feedback template includes 8 fields. Enable citizens to report road defects and provide feedback on road maintenance quality. Free to customize and use on ZenBuild.

• Reporter Name (text, optional)
• Email (for follow-up) (email, optional)
• Exact Location or Address of Issue (text, required)
• Issue Type (dropdown selection, required) — options: Pothole, Cracked Pavement, Missing Sign, Faded Lane Markings, Flooding, Debris on Road
• Severity (dropdown selection, required) — options: Minor (Bump), Moderate (Swerve-Worthy), Severe (Wheel-Damaging), Dangerous (Emergency)
• Issue Previously Reported? (multiple choice, required) — options: Yes, No, Unsure
• Photo of Issue (file upload, optional)
• Additional Details (long text, optional)