JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
COVID-19 Vaccination Interest
This form will be used to sign Transportation employees up for their first round of the COVID vaccination, beginning Monday 2/8/2021.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Name (First, Last)
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Female
Male
Ethnic Background
*
American Indian / Alaska Native
Asian
Native Hawaiian / Pacific Islander
White / Caucasian
Prefer not to answer
Phone Number
*
Your answer
Street Address
*
Your answer
Zip Code
*
Your answer
City
*
Your answer
Best Day and Time for Vaccination
You will need at least an hour window to receive your vaccination. This includes a sit time of 20-30 minutes after you receive the vaccination to ensure your are free from immediate adverse reactions.
Best Day(s) - Choose all that apply
*
Monday
Tuesday
Wednesday
Thursday
Friday
Required
Best Time(s)
*
Your answer
Send me a copy of my responses.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of School District U-46.
Report Abuse
Forms
