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1. Your age (years)
 
{under 20}
 
{21 – 30}
 
{31 – 40}
 
{41 – 50}
 
{51 – 60}
 
{over 60}
 
 
 
2. Your highest completed level of education
 
{Elementary school}
 
{High school}
 
{College degree}
 
{Graduate degree}
 
{Postgraduate or Doctor}
 
{Other (please specify) }
 
 
 
3. Your gender
 
{Female}
 
{Male}
 
 
Comment:
   
 
 
Please rate the following service items at our restaurant on a scale of 1 to 5.
1 (Poor) 2 3 4 5 (Excellent)
Friendliness of staff
Staff's knowledge of the menu
Attentiveness of staff
 
 
Comment:
   
 
 
Please rate the following regarding the ambiance of our restaurant on a scale of 1 to 5.
1 (Poor) 2 3 4 5 (Excellent)
Cleanliness
Lighting
Music
Comfort
Include comment box
 
 
Comment:
   
 
 
Please rate the following items regarding our menu on a scale of 1 to 5.
1 (Poor) 2 3 4 5 (Excellent)
Quality of food
Menu variety
Menu pricing and value
 
 
Comment:
   
 
 
 
How likely are you to recommend our restaurant to a friend or colleague?
 
Very unlikely
 
Somewhat unlikely
 
Neutral
 
Somewhat likely
 
Very likely
 
 
 
Please share any suggestions for improving our restaurant.
   
 
 
 
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Last Name : 
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