Girls Inc. of Chicago: Community Covid-19 Survey

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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 katherineg@girlsincofchicago.org.

Email *

How did you learn about this survey? *

Girls. Inc of Chicago Email or Flyer

A sign, poster, or ad in my community

Girls Inc. of Chicago Website

GIoC Vaccine Champion: Shaleece Edwards

GIoC Vaccine Champion: Shirley Pryor

GIoC Vaccine Champion: Maricela Roman

Other:

What is your Zip Code? *

What is your age range: *

14-17

18-24

25-34

35-49

50-64

65+

What is your race?

Black

Multiracial

Native American

White

Asian / Pacific Islander

Hispanic / Latinx

Other:

Clear selection

Preference for personal communication *

Emails

Text Messages

Phone Calls

Other:

Required

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