Quick Reading Response Form

For the past few years I haven't been able to settle on a way to have students respond to reading in a meaningful way. This year I am trying something my co-worker, Katy has done in the past with 3rd graders (I had to modify it a little). Here's what it looks like:

See it in google docs here

I know my name is on the pdf...but I'd be more than happy to email a copy in a regular word document  - I don't know how to make google docs editable!

This form will be in my students' reading folder, which houses all daily 5 and cafe handouts/assignments. In the three prongs down the middle I have a bunch of lined paper that is meant for responding to reading. I don't know how I plan on keeping up with reading these responses, but hopefully I'll figure that out! Any suggestions?