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* 1. Do you plan to receive the COVID-19 vaccine, a series of two shots for full coverage, when it becomes available?

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* 2. Do you belong to any of the following priority groups for vaccination? Check all that apply.

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* 3. Have you been laboratory confirmed to have had COVID-19 within the last 90 days?

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* 4. If you have children under the age of 18 years old, do you plan to have them take a COVID-19 vaccine for children as soon as one becomes available?

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* 5. What is your age?

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* 6. Do you live in Comanche County, Kansas?

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* 7. How do you receive information on the COVID-19 updates and vaccine availability?

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* 8. If you would like to be contacted once we have vaccine available for you, please fill out your contact information. We will call you to schedule an appointment.

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* 9. Do you have anyone else in the household that is wanting to receive the COVID-19 vaccine? If so, please enter their Name/ Age/Employment/if they are high risk due to a pre-existing medical condition/ phone number to reach them to schedule vaccination appointment.

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