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This form was created for free using google forms and it sends info to a private google spread sheet.

Sample form

Here is the data entered from the form...

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Working on geocoding a google spreadsheet list of addresses so they can be easily mapped. This site got me close but I am still working on it.
http://gmaps-samples.googlecode.com/svn/trunk/spreadsheetsgeocoder/fixgeocodedspreadsheet.htm
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