Public Survey Ouestionnaire 2021
Name
First Name
Last Name
Age
Education Qualification
Please Select
10+
12+
Graduate
Post Graduate
Contact
Please enter a valid phone number.
Format: (000) 000-0000.
email
City
State
Please Select
Andhra Pradesh
Arunachal Pradesh
Assam
Bihar
Chhattisgarh
Goa
Gujarat
Haryana
Himachal Pradesh
Jharkhand
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
Odisha
Punjab
Rajasthan
Sikkim
Tamil Nadu
Telangana
Tripura
Uttarakhand
Uttar Pradesh
West Bengal
Were you infected with Covid-19?
Yes
No
Do you have any other health issues?
Yes
No
Please specify
How many members do you have in your family?
How many members in your family were infected with Covid-19?
Please Select
None
Only me
1
2
3
4
More than 4
How many members in your family have any health issues?
None
1
2
3
More than 3
Please specify the health issues facing in your family
Did you change/lost your job due to Covid-19?
Yes
No
How much did Covid-19 affect your income?
0%-20%
21%-40%
41%-60%
61%-80%
81%-99%
Do you like work from home?
Yes
No
Not much
Do you work from home currently?
Yes
No
I'm a/an
unemployed
self employed
private job employee
govt job employee
How much do you earn currently in a month?
less than 7k
less than 12k
less than 30k
more than 30k
Are you satisfied with your income?
Not much
1
2
3
4
Well satisfied
5
1 is Not much, 5 is Well satisfied
Submit
Should be Empty: