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Customer Feedback Form

Please take a moment to complete this form so we can ensure that we maintain our high standards of quality, service and cleanliness.

Complete the fields and then click the [ Submit ] button at the bottom of the page. * = Required Field
* Date of Visit:   Time of Visit: 
Employee Who Served You:
First Visit ? Yes  No 
What Did You Order ?
  Rating Scale of 1 - 5. 5 being the best,1 being the worst.

How would you rate your overall visit?

5   4   3   2  
Food Quality : 5   4   3   2  
Service : 5   4   3   2  
Cleanliness : 5   4   3   2  
Value : 5   4   3   2  
* Comments & Suggestions:
Name:
*Phone Number   (Home):   (Work): 
Street Address:
City:
State:   Zip Code:
* Email Address:
 

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