COVID-19 Local Response Business Survey
RequiredRequired Question(s)
1.
Please provide contact info for future outreach and sharing of resources.  This information will not be used for SPAM.

First Name:
Company Name:
Work Phone:
Email Address:
emailaddress@xyz.com

Required 2.
Is your business open the next two weeks?
Yes
No
Not sure
Other  
  • Comment:

  • 500 characters left.
Required 3.
Do you have altered business hours the next two weeks? If yes please provide the hours in comment section.
YES
NO
Not sure
Other  
  • Comment:

  • 500 characters left.
Required 4.
Do you have online orders? Please provide your link for your online orders in the comment section.
YES
NO
We plan on providing in the future
Other  
  • Comment:

  • 500 characters left.
Required 5.
Do you have curbside pick up? Please provide your link or instructions in the comments section.
YES
NO
Will plan on providing in the future
Other  
  • Comment:

  • 500 characters left.
Required 6.
Are you currently experiencing a financial crisis that requires information on business resources?
YES
NO
After two weeks we will be in crisis
Other  
  • Comment:

  • 500 characters left.
Required 7.
Could your business use volunteers to assist with deliveries for your business? 
YES
NO
We plan on needing this in the future
Other  
  • Comment:

  • 500 characters left.
Required 8.
For our larger employers- Do you have supplies, funds, volunteers that you want to donate to the community food pantries or community centers? 
YES
NO
Yes in the future
Other  
  • Comment:

  • 500 characters left.
Required 9.
Please list issues or suggestions you may have for your community.
 

50 characters left.