Customer Feedback Form

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

*What restaurant did you visit?		Villa Fresh Italian Kitchen	Bananas
		Casa Java	GreenLeaf's
		South Philly Steak & Fries	Everything Yogurt
*Restaurant Location:
* 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 1
Food Quality :	5 4 3 2 1
Service :	5 4 3 2 1
Cleanliness :	5 4 3 2 1
Value :	5 4 3 2 1
* Comments & Suggestions:
Name:
Phone Number (Home):	(Work):
Street Address:
City:
State:	Zip Code
* Email Address:

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