Survey
Contact Information
First Name:
*
Last Name:
*
(Last Name)
Phone #:
*
(
)
-
Email:
*
Date
Date of visit:
*
Restaraunt
Location:
Please select...
Chesterfield
Downtown
Cleanliness of the Restaraunt:
1
2
3
4
5
Comments:
How often do you visit:
Less then 1 time a month
1 to 2 times a month
3 to 5 times a month
6 or more times a month
Service
Server / Counter Person
Your server's name:
Rate the server / counter person:
1
2
3
4
5
Comments:
Was the server courteous:
Yes
No
Was the server informative:
Yes
No
Was the server prompt and efficient:
Yes
No
Food
What did you order?
Quality of your entree:
1
2
3
4
5
What dishes would you like to see added to the menu:
General
Please rate your overall dining experience:
1
2
3
4
5
Would you recomend us to a friend?
Yes
No
Why or why not:
Do you plan on returning to our restaraunt:
Yes
No
Why or why not
Additional comments or suggestions:
Please contact me about my experience:
Yes
No
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