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Vaccine Appointment Registration Experience Survey

Measures how easily people can find, register for, and confirm vaccination appointments across online, phone, and walk-in channels, and pinpoints exactly where the process breaks down. Built for health systems, pharmacies, and public health programs; the AI follow-up interview reconstructs what actually happened at the moment registration got difficult, not just a friction score.

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Sample questions

A preview of what’s in the template. Every question is editable before you launch.

13 questions · ~7 min
Q01
Message

Thanks for taking a few minutes to tell us about registering for your vaccine appointment! Your honest feedback helps us make the process smoother for everyone. This will take about 7 minutes.

Q02
Multiple ChoiceRequired

Which vaccine were you registering for? (Template note: replace these options with the vaccines your program offers.)

  • Seasonal flu shot
  • COVID-19 vaccine or booster
  • RSV vaccine
  • Childhood immunization
  • Travel vaccine
Q03
Multiple ChoiceRequired

How did you complete your registration?

  • Online portal or website
  • Phone call
  • Walk-in without an appointment
  • Mobile app
  • Through my employer or school
  • Someone else registered for me
Q04
Opinion ScaleRequired

Overall, how easy or difficult was it to register for your appointment?

Scale: 1 – 7
Min:Very difficultMax:Very easy
Q05
Multiple Choice

About how long did the registration process take, from start to confirmation?

  • Less than 5 minutes
  • 5-15 minutes
  • 16-30 minutes
  • More than 30 minutes
  • I gave up before finishing
Q06
MatrixRequired

Rate each part of the registration process.

4 rows × 5 columns
  • Finding an available appointment slot
  • Entering personal or insurance information
  • Receiving a confirmation message
  • Getting reminders before the appointment
Columns: Very poor · Poor · Fair · Good · Very good
Q07
Multiple Choice

Did you run into any of these problems while registering? Select all that apply.

  • Website or app errors
  • Long wait times on hold
  • Confusing instructions
  • No appointment slots available
  • Language barriers
  • Had to re-enter information multiple times
Q08
Opinion ScaleRequired

How likely are you to recommend this registration process to a friend or family member who needs a vaccine?

Scale: 0 – 10
Min:Not at all likelyMax:Extremely likely
Q09
AI Interview

Reconstruct the specific moment the respondent's registration went smoothly or got difficult: what step they were on, what exactly happened (an error message, a hold time, confusing wording), and how they resolved it — called back, asked staff, or gave up. If they reported a problem or rated ease low, dig into what would have fixed it on the first try. If they gave up before finishing, find out whether and how they eventually got vaccinated.

Q10
Long Text

What one change would have made registering for your vaccine easier?

Q11
Multiple Choice

Which age group do you fall into?

  • Under 18
  • 18-29
  • 30-44
  • 45-59
  • 60-74
  • 75 or older
  • Prefer not to say
Q12
Multiple Choice

Which best describes why you were registering?

  • General public
  • Healthcare worker
  • High-risk or chronic condition
  • Caregiver registering for someone else
  • Employer or school-sponsored program
  • Prefer not to say
Q13
Message

That's everything — thank you! Your answers will be used to fix bottlenecks in the vaccine registration process and reported back to the team running this program.

What’s included

  • AI follow-ups

    Adaptive probes on open-ended answers that pull out detail a static form would miss.

  • Attention checks

    Built-in safeguards against rushed answers and low-quality respondents.

  • AI-drafted copy

    Wording, ordering, and branching written by the AI — tuned to your research goal.

  • Auto report

    Themes, quotes, and a plain-English summary write themselves once responses come in.

How it compares

We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.

Why this template

  • Includes a dedicated opinion-scale ease rating plus a separate recommend-likelihood question, giving both a friction score and an NPS-style signal
  • A matrix question rates each individual step of the registration process (finding, registering, confirming), pinpointing exactly where breakdown occurs across online, phone, and walk-in channels
  • An AI follow-up interview reconstructs the specific moment registration went smoothly or went wrong, capturing what actually happened rather than just a satisfaction number
  • Covers channel completed, time-to-confirmation, specific problems encountered, and an open-ended 'one change' question, then closes with a transparent note on how responses will be used to fix bottlenecks

Jotform

COVID-19 Vaccine Registration Form Template

This is a data-intake form for signing people up for a vaccine appointment (name, contact info, appointment slot), not a survey measuring how the registration experience went. It's a fielding-ready form template but serves a different purpose than an experience/friction survey. Useful for the registration step itself, not for diagnosing where people struggled.

What it does well

  • Easy drag-and-drop customization within a widely used form builder
  • Broad template library and integrations for actual appointment intake
  • Free to use and quick to deploy for basic registration collection

Where it falls short

  • Static field-based form with no adaptive follow-up probing into why a step failed
  • No automated per-response quality scoring or synthesized report on friction points
  • No AI or voice interview capability to reconstruct what happened at the moment of difficulty

SurveySparrow

Vaccination Registration Form Template | COVID - 19

Also framed as a registration form (collecting appointment/registration details) rather than a post-registration experience survey. SurveySparrow's conversational, chat-style format is a nice touch for completion rates, but the template itself is about capturing registration data, not diagnosing channel-specific friction. Fielding-ready as a form, not as a diagnostic experience study.

What it does well

  • Conversational, chat-like question flow that can feel friendlier than a static form
  • Supports multi-channel distribution for collecting registrations
  • Simple to launch without custom setup

Where it falls short

  • No adaptive AI interviewing to dig into a specific bad moment in the registration process
  • No automated quality scoring per response or auto-generated diagnostic report
  • No published methodology or prompt transparency behind its question logic

Ready to launch?

Open this template in the editor. Every part is yours to change before the first respondent sees it.

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