COVID-19 Viewer Survey
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Is the food enough in your household during the pandemic?
Yes
No
How do you get your groceries during the pandemic?
Buy in store
Delivery
Provided by the government
Do you still have work or are you currently employed?
Yes
No
Is the company you're working to a remote company or allows you to work at home?
Yes
No
Would you allow your child to go to school when the government permits the schools to open?
Yes
No
Will you be able to dine in a restaurant?
Yes
No
Will you attend an indoor event?
Yes
No
Will you attend an outdoor event?
Yes
No
Should the health center have a walk-in or drive by COVID-19 testing sites?
Yes
No
Should an individual wear face masks outside?
Yes
No
Should an individual wear face shield outside?
Yes
No
Do you think physical and social distancing are helping in this pandemic?
Yes
No
Who should receive the vaccine first?
Senior citizens
Health workers
Frontliners
Children
Other
How do you feel about the government officials in terms of how they respond to this pandemic?
Positive
Negative
Both
I don't care
Do you think hospitals have enough bed to accommodate COVID-19 patients?
Yes
No
I don't have any idea
What are the helpful vitamins in order to prevent having COVID-19 infection?
Vitamin C
Vitamin D
Zinc
ALL
Do you have any additional suggestions or comments that you would like to share?
Would you like to submit anonymously?
Yes
No
Your Name (Optional)
First Name
Last Name
Age (Optional)
Your Email (Optional)
example@example.com
Your Phone Number (Optional)
Please enter a valid phone number.
Format: (000) 000-0000.
Your Gender (Optional)
Please Select
Male
Female
Location (Optional)
Submit
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