Surveypoint

Q1

Name

First Name

Q2

Name

Last Name

Q3

Phone Number

Q4

Email

Q5

Please select the applicable one for you

Yes

No

Don't want to answer

Not Applicable

Have you had the corona vaccine?

Have you had corona recently?

Have you shown signs of corona recently( Fever,Cough, Difficulty breathing, etc.)

Have all of your family had the corona vaccine?

Have you or is anyone in your household above the age of 65, pregnant or suffering from any pre-existing medical conditions (heart diseases, lung diseases, endocrine disorders, etc.)

Q6

Date

Q7

Date

Q8

Liturgy Registration Template 1 -Form Fill

Name

Name

Phone Number

Email

Please select the applicable one for you

Date

Date

Signature