Parent/ Student COVID-19 Vaccine Survey
The Cobra Health Center is currently requesting input from the Fountain Lake community regarding the COVID-19 vaccine for individuals who are 16 and older. We are asking this information to get an idea of how many vaccinations we need to order.
Have you received the first round of the COVID-19 vaccination?
Have you received the second round of the COVID-19 vaccination?
Yes, I have received both vaccinations.
No, but I will be receiving my second vaccination soon.
No, I have chosen to not take the second round of the vaccination.
If the COVID-19 vaccinations were available at the Cobra Health Center, would you be interested in receiving the vaccination? *This includes individuals who are 16 and older.
If you have a child who is 16 or older, would you be interested in receiving the vaccine with them?
If you are not planning on taking the COVID-19 vaccine, please feel free to let us know why. We are interested in feedback from our community.
If you are interested in receiving the vaccine at the Cobra Health Center in the future, please list your first and last name, as well as your phone number, so we can contact you when our clinic has been scheduled to distribute the COVID-19 vaccinations. If you are uninterested in receiving the vaccine, we will not contact you.
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This form was created inside of FOUNTAIN LAKE SCHOOL DISTRICT.