FEEDBACK
 

Your Information:

Your Name: *

Your Street:

Your City/Province:

Your Postal Code:

Your Phone Number: *

Your Email: *

Age Group: *

18 & under

19-30

31-40

41-55

56 +

Occupation:

 

Information About Restaurant Location:

Restaurant: *

Address of Restaurant:

City/Province:

Date & Time Visited: *

How did you hear about us? *

Newspaper

Radio Station

TV

Driving By

Word of Mouth

 

 

 Other:

# of people in your party: *

Did you have to wait for a table? *

No

Yes

 How Long? 

Was the restaurant clean? *

Yes

No

Was your table clean?

Yes

No

What area was not clean?

Server's Name:

Did you have *

Breakfast

Dinner

Lunch

 

Please Rate Our Food On:

 

Taste: *

Excellent

Very Good

Fair

Poor

Temperature: *

Excellent

Very Good

Fair

Poor

Portion Size: *

Excellent

Very Good

Fair

Poor

Price: *

Excellent

Very Good

Fair

Poor

 

Please Rate Your Service Today:

Promptness: *

Excellent

Very Good

Fair

Poor

Friendliness: *

Excellent

Very Good

Fair

Poor

Attentiveness: *

Excellent

Very Good

Fair

Poor

Accuracy: *

Excellent

Very Good

Fair

Poor

 

Additional Information:

How would you rate this restaurant? *

Excellent

Very Good

Fair

Poor

How often do you visit Humpty's Family Restaurants? *

1st Time

Weekly

Monthly

One or Two times a year

Other Comments and Suggestions: