| Date | |
| Time | |
| How often do you eat here each month? | |
| How did you hear about us? | |
| What is your favorite menu item? | |
| What additional menu item would you like us to offer? | |
| What is your age group? | |
| How would you rate the following areas? | |
| Food Quality | |
| Friendliness | |
| Menu Selection | |
| Cleanliness | |
| Price / Value | |
| Speed of Service | |
| Your satisfaction is our #1 goal. Please provide the following information so we can contact you. | |
| Your Name | |
| Your Phone Number | |