COVID-19 Vaccine Appointment Form
Appointment
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Zip Code
Questionnaire
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What is your gender assigned to birth?
Please Select
Female
Male
Intersex
What is your current gender?
Please Select
Female
Male
Transgender Man
Transgender Woman
Gender-neutral
What is your ethnicity?
Please Select
American Indian or Alaskan Native
Asian or Pacific Islander
Black or African American
Hispanic or Latino
White
Other
Height (ft)
Weight (lb)
Are you currently employed?
Yes
No
Do you work form home?
Yes
No
What is the possible nearest date for you to work from main office?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Zip code for your main office
How often do you go in person to your main workplace currently?
One day in a week
2-4 days in a week
5 or more days in a week
Does your main workplace have social distancing measures in place?
Yes
No
Do you and other people in your main workplace use personal protection equipment such as masks?
Yes
No
How do you get to work? (select all that apply)
By own car
Carpool
Ride share
Public transportation (train, bus, etc)
Walk / bike
Other
In general, how many people do you physically interact with in your main workplace?
No one
1-10 people
11-30 people
31-50 people
More than 50 people
How many people live in your household? (including you)
I live alone
2 people
2-4 people
More than 4 people
Is there anyone in your household who is older than 64?
Yes
No
Is there anyone in your household who attend school or child care?
Yes
No
Submit
Should be Empty: