JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
COVID-19 Vaccine Waitlist
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Phone Number
*
Your answer
Email
*
Your answer
Select ONLY ONE of the following categories that applies to you.
*
Long-term care facility residents
Front line Health care personnel
Persons not directly involved in patient care but potentially exposed to infectious material that can transmit disease among or from health care personnel and patients
Persons ages 65 and older
Cancer
Chronic kidney disease
COPD
Down Syndrome
Immunocompromised state (weakened immune system) from solid organ transplant or from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, or use of other immune weakening medicines
Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2)
Severe Obesity (BMI ≥ 40 kg/m2)
Pregnancy
Sickle cell disease
Smoking
Type 2 diabetes mellitus
None of the above
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
