COVID-19 Vaccine Form
Due to a large amount of responses, we are only able to take responses from the state of Georgia right now. Please check back, we will continue to take other states soon! (Form intended for Georgia Residents only at this time. )
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Name *
Age *
Phone Number *
Location (*Georgia Residents Only) *
Zip Code *
What is the maximum distance you are willing to travel to receive your COVID vaccination? *
Do you a have preferred time and/or day to schedule your vaccine appointment? If so, please list below. *
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