Anywhere that masking and "social distancing" (really, physical distancing) are MANDATED is an attempt at a "US Consititution Free" zone. If I am understanding Mr. Gohmert's comments I think the Insurrection Act could be used in any city or state with masking and social distancing mandates. Need to dig on Q drops about this.
My state also uses "exemption forms". In late 2018 I had an extensive (half hour or more) phone conversation with a state official in my state about my concerns about the situation with vaccine safety and exemptions. I asked that the state inform parents that medical exemption was available and I also wanted the state to look at vaccine safety. Not sure what happened by the state (or else our local school district) doubled down on making it hard to "get" exemptions. The form such as you showed demands parents admit they are in some fashion putting their child at risk, though the opposite is demonstrably true (flu shots increase the risk of other respiratory illness, including coronavirus, for example) and also allows the school to "segregate" (exclude) children by vaccine status also requiring the public sharing of what should be, imo, HIPPA protected information.
Parents should not lose legally and constitutionally protected freedoms via a state bureaucracy demand for a form.