In writing, I have created a similar form. This form allows students to be metacognitive about what area of writing they need most support. As is suggested as a strategy in teaching of maths, from this, I can then create flexible focus groups to support multiple learners at once, in an area which is purposeful for them (Chapin, O'Connor, & Anderson, 2009).
The writing form:
More recently, at the end of term 3, I created a form for students to share their ideas about how they enjoy to learn.
Chapin, S.H., O'Connor, C., & Anderson, N.C. (2009). Classroom discussions: Using math talk to help students learn. California, USA: Math Solutions