[Company Name] [Street Address] [City, ST ZIP Code]	How can we improve?

Please take a moment to help us improve your experience at [Company Name]. When you’re done, please drop the questionnaire in the blue box at the front of the store.

Product Quality

How often do you come to [Company Name]? Every day 4 or 5 times a week 3 or fewer times a week First time	How would you rate our [type of products]? Consistent high quality Generally good Quality varies daily Poor quality
What do you typically purchase? [product 1] [product 2] [product 3] [product 4] [product 5] Other	How would you rate our [type of products]? Consistent high quality Generally good Quality varies daily Poor quality

Service and Environment

How long did you wait for your order to be taken? Immediate service Less than 1 minute 1 to 3 minutes More than 3 minutes	How long did you wait for your product after ordering? Less than 1 minute 1 to 3 minutes 3 to 5 minutes More than 5 minutes
How would you rate the staff? Friendly and helpful Average Varies on each visit Poor service	Was the store clean and inviting? Yes No

Additional Comments

About You (optional)

Name
Address
Phone
Email

May we add you to our mailing list, which offs news and exciting promotions?	□ Yes	□ No

Thank you for your participation!