Guest Comment Form

Fields with an * are required

First Name *
Last Name *
Address *
City *
State *
Zip *
Phone *  (ie: xxx-xxx-xxxx)
E-Mail

 
Tell us where/when you visited our restaurant *
 
Restaurant Location *  (ie: Street, City, State)
Date of Visit *
Time of Visit *
Number in Party *
Server
Manager

 
Please rate your visit based on the following *
 
 
Very
Satisfied
      Very
Dissatisfied
a. Atmosphere
5 4 3 2 1
 
b. Cleanliness
5 4 3 2 1
 
c. Food Quality
5 4 3 2 1
 
d. Food Preparation
5 4 3 2 1
 
e. Service
5 4 3 2 1
 
f. Price/Value
5 4 3 2 1
 
g. Portions
5 4 3 2 1
 
h. Management Visible
5 4 3 2 1
 
Based on your visit, how likely are you to return?
 
 
Likely       Not Likely
 
5 4 3 2 1
 
If there was a problem was it resolved to your satisfaction     Yes   No
 

 
Additional Comments
 
   
 





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Guest Comment Form

Fields with an * are required

First Name *
Last Name *
Address *
City *
State *
Zip *
Phone *  (ie: xxx-xxx-xxxx)
E-Mail

 
Tell us where/when you visited our restaurant *
 
Restaurant Location *  (ie: Street, City, State)
Date of Visit *
Time of Visit *
Number in Party *
Server
Manager

 
Please rate your visit based on the following *
 
 
Very
Satisfied
      Very
Dissatisfied
a. Atmosphere
5 4 3 2 1
 
b. Cleanliness
5 4 3 2 1
 
c. Food Quality
5 4 3 2 1
 
d. Food Preparation
5 4 3 2 1
 
e. Service
5 4 3 2 1
 
f. Price/Value
5 4 3 2 1
 
g. Portions
5 4 3 2 1
 
h. Management Visible
5 4 3 2 1
 
Based on your visit, how likely are you to return?
 
 
Likely       Not Likely
 
5 4 3 2 1
 
If there was a problem was it resolved to your satisfaction     Yes   No
 

 
Additional Comments