Name *

First Name

Last Name

Date of Visit

MM

DD

YYYY

Date of Birth

MM

DD

YYYY

Phone

(###)

###

####

Server Friendliness

Scale of 1-5, 1 being worst, 5 being best

1

2

3

4

5

Server Timeliness

Scale of 1-5, 1 being worst, 5 being best

1

2

3

4

5

Server Knowledge

Scale of 1-5, 1 being worst, 5 being best

1

2

3

4

5

Food Quality

Scale of 1-5, 1 being worst, 5 being best

1

2

3

4

5

Food Appearance

Scale of 1-5, 1 being worst, 5 being best

1

2

3

4

5

Setting Cleanliness

Scale of 1-5, 1 being worst, 5 being best

1

2

3

4

5

Setting Comfort

Scale of 1-5, 1 being worst, 5 being best

1

2

3

4

5

Setting Ambiance

Scale of 1-5, 1 being worst, 5 being best

1

2

3

4

5