Girls Inc. of Chicago: Community Covid-19 Survey
Thank you for your interest in learning more about Covid-19 Vaccinations and sharing your perspective with us!
After completing this form, you'll receive a $15 gift card, sent via email to the address provided. You can expect the survey to take approximately 15 minutes to complete.

Individual community members ages 14 and above are eligible to complete the survey and receive the gift card only once between 10/1/21 and 12/31/21.
If you have any questions or challenges with this form, please contact Girls Inc. Program Manager Kate Gilbert at
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Email *
How did you learn about this survey? *
What is your Zip Code? *
What is your age range: *
What is your race?
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Preference for personal communication *
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