Feedback Form
 
* Required Fields
How often, on average, do you visit this restaurant? *
Daily
Weekly
Twice per Week
Monthly
     
Which of the following items did you order today? *
Fish
Chicken
Shrimp
Soft Drinnk
Other
 
What else did you order?
 
How much did you spend in total ($)? *
 
How old are you? *
Under 18
18-24
25-44
45-60
Over 60
 
How do you rate the following? *
Speed of Service
Very Good
Good
Ok
Poor
Very Poor
Cleanliness
Very Good
Good
Ok
Poor
Very Poor
Quality of Food
Very Good
Good
Ok
Poor
Very Poor
Choice of Food
Very Good
Good
Ok
Poor
Very Poor
 
How do you rate the overall performance of this restaurant? *
(Use a score 10 for excellent and 1 for poor)
 
Are there any other comments you would like to make?
 
For coupons plz fill in the following:
Name * :
Address * :
City * :
State * :
Zip * :
Phone * :