In my travels across the interwebs, I have found serval worksheets that ask students to refer back to the text. They always come with texts at the top, but I often find that they are too hard or too easy for my kiddos, so I designed this one.
You can fill in the text and the questions, while sticking with a familiar template. This would make a great center or a quick formative assessment.
This form is fillable, so you should be able to type right in to the box. You can even type the answers you are hoping for on the lines to create an answer key for a TA or parent volunteer
Border from Ink-N-Little Things (http://www.teacherspayteachers.com/Store/Ink-N-Little-Things). Fonts used: Return to Sender, Pea Celestial