| Which restaurant did you visit? |
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| Time of Visit: |
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| Date of Visit: |
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| What items did you purchase? |
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| How often do you eat at Kanpai? |
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| How far did you travel? |
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| Overall Experience: |
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| Quality of Food: |
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| Attitude of Employees: |
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| Speed of Service: |
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| Cleanliness: |
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| Chef's Performance: |
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| Chef's Name: |
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| Waitperson's Name: |
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| Comments or Suggestions: |
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| Your Age: |
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| Your Name: |
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| Your Email Address: |
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| Your Street Address: |
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| Your City: |
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| Your State: |
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| Your Zip: |
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| Your Phone Number: |
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