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Which Restaurant Did You Dine at? (required)         King Street    Niu Valley    Pearl City
Dining Date:
Dining Day:
Dining Period: Choose one(required)         Lunch    Dinner     Take Out     Special Event
Check / Reciept #:
Server Name or Description#:
Service Excellent  Good  Average  Fair  Poor  N/A
Staff Attitude or Demeanor Excellent  Good  Average  Fair  Poor  N/A
Beverage Quality Excellent  Good  Average  Fair  Poor  N/A
Food Quality Excellent  Good  Average  Fair  Poor  N/A
What other items would you like to see on our menu?
How likely are you to recommend our restaurant to family members or friends?
10 = Very Likely 0 = Very Unlikely              
10 9 8 7 6 5 4 3 2 1 0
How did you find out about us? (choose one)
TV Radio Direct Mail Ad Web Site
Search Engine (google, bing, yahoo, other)
On Line Yellow Pages
Facebook Twitter Yelp
Star Advertiser MidWeek
Friend Family Business Associate
Drive By Other
What other resturants do you frequent? Name as many as possible?
Any additional comments about your dining experience?
Contact Info (Optional)                                                                Join us on
Full Name
Street Address
Zip Code
Email Address
Phone Number
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