COVID-19 Vaccination Interest
This form will be used to sign Transportation employees up for their first round of the COVID vaccination, beginning Monday 2/8/2021.
* Required
Email address
*
Your email
Name (First, Last)
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Female
Male
Ethnic Background
*
American Indian / Alaska Native
Asian
Native Hawaiian / Pacific Islander
White / Caucasian
Prefer not to answer
Phone Number
*
Your answer
Street Address
*
Your answer
Zip Code
*
Your answer
City
*
Your answer
Best Day and Time for Vaccination
You will need at least an hour window to receive your vaccination. This includes a sit time of 20-30 minutes after you receive the vaccination to ensure your are free from immediate adverse reactions.
Best Day(s) - Choose all that apply
*
Monday
Tuesday
Wednesday
Thursday
Friday
Required
Best Time(s)
*
Your answer
Send me a copy of my responses.
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