This interest form is for Benton County residents who are age 65 years or older who would like to get the Moderna COVID-19 vaccine. This survey is NOT to schedule an appointment at this time. It will be used to gauge interest and collect contact information so when vaccine becomes available local public health will reach out to you to schedule an appointment. Please fill out ONE survey for each person age 65 or older who lives in Benton County. Remember to click on the "done" button at the bottom of the page when you are finished. 

We will contact you when we have Moderna vaccine available. If you listed an email address we will contact you through email so please be checking that daily. Only fill this survey out once. We will keep you on our list until you have been able to get an appointment. You MUST BE 65+ or we  will remove you from this list.

**NOTE: We will not have vaccine available for 1st dose appointments the week of March 1st, 2021**

Thank you,
Benton County Public Health

Question Title

* 1. First & Last Name (of person 65+)

Question Title

* 2. Age

Question Title

* 3. Phone Number

Question Title

* 4. Address

Question Title

* 5. City of residence

Question Title

* 7. Zip Code

Question Title

* 8. Email Address (if you have one)

Question Title

* 9. I agree to receive email notifications from Benton County Public Health regarding COVID-19 vaccination at the email provided above.

Question Title

* 10. Additional information you would like to provide.

T