COVID Vaccine Questions

1. Tell us what you need to know about the COVID-19 vaccine and/or steps to getting vaccinated: *This question is required.

Optional
About You
It helps us learn more about your eligibility for the vaccine.

Questions about anything on this form? Contact Dave Bartkowiak -- dbartkowiak@wdiv.com

2. City, State

3. Age

4. Name

5. Email This question requires a valid email address.

6. Phone number