Vaccination Plan Survey
Full Name
First Name
Last Name
Email Address
example@example.com
Please indicate your vaccination status.
I have not scheduled my first shot yet.
I have scheduled my first shot.
I had my first shot.
I had both of my shots.
When will you get your first shot?
-
Month
-
Day
Year
Date
When did you get your first shot?
-
Month
-
Day
Year
Date
When did you get your second shot?
-
Month
-
Day
Year
Date
Do you plan to receive the COVID-19 vaccine?
Yes
No
Submit
Should be Empty: