Q01
Message
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Seasonal Flu and COVID-19 Vaccine Intentions Survey
Tracks whether people plan to get vaccinated for flu and COVID-19 this season, what's holding hesitant respondents back, which access barriers get in the way, and which information sources they trust most. An AI follow-up probes the specific concerns behind low intention scores so public health teams can address the actual objection rather than a guess.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
13 questions · ~7 min
Q02
Multiple ChoiceRequired
Did you get a flu vaccine last flu season (roughly September through March)?
- Yes
- No
- Not sure
Q03
Opinion ScaleRequired
How likely are you to get a flu vaccine this season?
Scale: 1 – 7
Min:Definitely will notMax:Definitely will
Q04
Multiple ChoiceRequired
Which best describes your current COVID-19 vaccination status?
- Never received a COVID-19 vaccine
- Received initial vaccine series only
- Received initial series plus one or more boosters, but not the most recent update
- Up to date with the most recently recommended COVID-19 vaccine
- Not sure
Q05
Opinion ScaleRequired
How likely are you to get the currently recommended COVID-19 vaccine or booster this season?
Scale: 1 – 7
Min:Definitely will notMax:Definitely will
Q06
Multiple Choice
Which of the following, if any, describe reasons you might not get a flu or COVID-19 vaccine this season?
- Concerned about side effects
- Don't think I need it / low personal risk
- Don't think it works well enough
- Had a bad reaction before
- Haven't gotten around to it
- Prefer to build immunity naturally
- Distrust of vaccine safety data
- Distrust of pharmaceutical companies or government
Q07
AI Interview
Explore the reasoning behind this person's likelihood ratings for flu and COVID-19 vaccination, especially if either score was neutral or low. If they selected specific hesitancy reasons, probe what evidence, source, or experience would actually change their mind, and whether their view differs between the flu and COVID-19 vaccines specifically. If they rated both highly, briefly confirm what motivates them to keep up to date rather than assuming it's automatic.
Q08
Matrix
How much do you trust each of the following sources for information about flu and COVID-19 vaccines?
7 rows × 5 columns
- Your doctor or nurse
- Pharmacist
- Local or state health department
- CDC or national public health agency
- Family and friends
- +2 more
Columns: Not at all trustworthy · Slightly trustworthy · Moderately trustworthy · Very trustworthy · Extremely trustworthy
Q09
Multiple Choice
In the past 12 months, has anything made it harder for you to get a vaccine you wanted?
- Cost or insurance concerns
- Difficulty finding an appointment
- Not enough time off work or school
- Transportation issues
- Nearest location too far away
- Not sure where to go
Q10
Multiple Choice
If you were to get vaccinated this season, where would you most likely go?
- Pharmacy
- Doctor's office or clinic
- Workplace or school vaccination event
- Community health center or public health clinic
- Not sure
Q11
Multiple Choice
What is your age range?
- 18-24
- 25-34
- 35-44
- 45-54
- 55-64
- 65 or older
- Prefer not to say
Q12
Multiple Choice
What is your health insurance status?
- Insured through employer
- Insured through government program (e.g., Medicare, Medicaid)
- Individually purchased insurance
- Uninsured
- Not sure
- Prefer not to say
Q13
Message
Thank you for sharing your perspective. Your responses will be combined with others to help public health teams understand vaccine plans and reduce barriers to access — no individual answers will be shared.
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
- Directly tracks intention for both flu AND COVID-19 vaccines in the same instrument, with separate status and likelihood questions for each rather than treating vaccination as one generic topic.
- Uses an AI follow-up interview (AI follow-up interview block) to probe the actual reasoning behind a respondent's likelihood ratings, so low scores get diagnosed instead of just recorded.
- Includes a dedicated reasons/barriers multiple-choice question plus a separate access-barrier question, letting public health teams distinguish 'won't' from 'can't' get vaccinated.
- Captures a trust-in-sources matrix and channel/location preference alongside age and insurance status, giving segmentable data for targeting outreach and messaging.
QuestionPro
COVID-19 Survey Template + Sample QuestionnaireThis is a general COVID-19 questionnaire template on an established survey platform, not a template purpose-built for tracking dual flu/COVID vaccine intentions or hesitancy reasoning. It's fielding-ready in the sense of being a static, editable questionnaire, but it isn't focused on the intention-vs-barrier-vs-trust structure this topic needs. Useful as a broad pandemic-attitudes starting point rather than a vaccination-intention diagnostic tool.
What it does well
- Backed by a mature, full-featured survey platform with extensive logic and reporting tools
- Provides a ready sample questionnaire so researchers aren't starting from a blank page
- Easy to customize question wording and branching within QuestionPro's builder
Where it falls short
- Static question set with no adaptive AI follow-up to probe the specific reasons behind vaccine hesitancy
- No automated per-response quality scoring or transparent prompt methodology
- Not structured around the flu+COVID dual-intention, trust-source, and access-barrier framework this topic calls for
Frequently asked questions
What questions are in the “Seasonal Flu and COVID-19 Vaccine Intentions Survey” template?
The template includes 13 ready-to-use questions, starting with: “Thanks for taking a few minutes to share your thoughts on flu and COVID-19 vaccines this season. There are no right or w…” · “Did you get a flu vaccine last flu season (roughly September through March)?” · “How likely are you to get a flu vaccine this season?”. The full set is previewed above, and every question is editable.
How long does this survey take to complete?
Respondents typically finish the 13 questions in about 7 minutes.
Can I customize this template?
Yes — every question, answer option, and the ordering is editable before you launch. You can add or remove questions, or ask the AI editor to rework the survey around your research goal.
Is this template free to use?
Yes. Open it in the editor and start customizing right away — no account required to try it, and the free plan covers launching your survey.
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.