Old City Hall Restaurant

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Complete the fields and then click the [ Submit ] button at the bottom of the page. * = Required Field

*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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