COVID-19 Vaccine Questions

Question Title

* 1. How likely are you to consider getting the vaccine in the future?

Very likely

Likely

Unlikely

Very unlikely

Question Title

* 2. What is your main concern with getting the COVID-19 vaccine?

Side Effects

Fertility/Pregnancy status

Safety of the vaccine

How the vaccine works

Cost

How well it works

Other (please specify)

Question Title

* 3. Are you open to being contacted to discuss your concerns about the vaccine?

Yes

No

Question Title

* 4. Please enter your contact information.

Name

Department

Email Address

Phone Number