COVID-19 Vaccine
Survey Form

Full Name
Email
Age

Have you received a COVID-19 vaccine?

Yes No

If yes, which vaccine did you receive?

Choose one Pfizer-BioNTech Comirnaty Moderna Spikevax AstraZeneca Vaxzevria Janssen (Johnson & Johnson)

If not, what makes it difficult for you to get a COVID-19 vaccine? (Select all that apply.)

I can’t go on my own (I have a physical limitation).
I don’t know where to go to get vaccinated.
I’m not eligible to get a COVID-19 vaccine.
I have a medical reason that makes me ineligible to get vaccinated (e.g., I have had a severe allergy to vaccines in the past).
I don’t have time off work.
Other (Briefly explain in the textbox below.)

If a COVID-19 vaccine were available to you, would you get it?

Yes, I would get it as soon as possible.
Yes, but I plan to wait to get it.
No
Not sure

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