Vaccine Interest Survey
We are conducting a survey to determine the interest level for Pfizer COVID-19 vaccine in children from 12-15 years of age.
What is the age of your child?
If Pfizer vaccine is granted emergency use authorization for children 12-15 years of age by the FDA, will you vaccinate your child?
Clear selection
If you choose to get your child vaccinated, which of our four counties would you be interested in receiving the vaccine in?
Clear selection
Submit
Never submit passwords through Google Forms.
This form was created inside of LMAS District Health Dept.. Report Abuse