To our customers, we thank you for dining with us! Our goal is 100% guest satisfaction, all day every day. At The Triple XXX Family Restaurant, we take pride in the quality of our food and service. Your comments help us to serve you better, so please take a moment to complete this handy form.

1. What is your name?

2. Your email address?

3. Your phone number?

4. You live in:
City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Other (* see below)

5. How often do you eat at Triple XXX Family Restaurant?
Very often Sometimes Seldom

6. Do you come to Triple XXX Family Restaurant for:
Breakfast Lunch Dinner Late-Nite

7. What items do you purchase?
I usually buy..

8. Do you have a favorite dish? Please tell us!:
I love to eat...

9. Would you purchase Triple XXX Root Beer in bottles if it were available?
Yes No

10. Are you satisfied with the service at Triple XXX Family Restaurant?
Yes, Always Usually Sometimes No, Never

11. How do you like the atmosphere?
Ideal Good Not bad Unpleasant

12. Did you know we have a non-smoking section?
Yes No

13. Is there anything you would like to see added to the menu?
I would like to see...

14. Comments to help us provide better service:
I think...

Thank you for sending us your impressions!

* Comments may be used as testimonials
(Only First Name, City, and State will be listed)