11th District COVID-19 Survey

From the office of State Representative Steve Bergquist

Question Title

* 1. When available, do you intend to get vaccinated for COVID-19?

Yes

No

Question Title

* 2. If you are currently eligible to receive the COVID-19 vaccine and have not received one yet, have you had issues finding a provider or scheduling an appointment?

Yes

No

N/A

Question Title

* 3. Do you have a child attending school remotely?

Yes

No

Question Title

* 4. If your child is currently attending remote schooling, would you prefer your child to attend in-person school?

Yes

No

N/A

Question Title

* 5. Are you or your family experiencing housing instability?

Yes

No

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* 6. Are you or your family experiencing food insecurity?

Yes

No

Question Title

* 7. Your responses are anonymous, so if you'd like a personal reply:
a. Send me an email; or
b. Leave your name and phone number (optional)