Customer Feedback Form

Date: [DATE]
Customer Name: [CUSTOMER_FULL_NAME]
Customer ID / Account Number: [ACCOUNT_NUMBER]
Email Address: [EMAIL_ADDRESS]
Phone Number: [PHONE_NUMBER]
Department/Location Visited: [DEPARTMENT_LOCATION]
Representative Assisted By (if applicable): [REPRESENTATIVE_NAME]

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1. Purpose of Feedback

Please help us improve our products and services by sharing your experience. Your feedback is valuable to us and will be used to enhance our offerings. This survey should take approximately [ESTIMATED_TIME_MINUTES] minutes to complete.

Order/Transaction Reference Number: [ORDER_REFERENCE_NUMBER]
Product/Service Purchased: [PRODUCT_SERVICE_NAME]

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2. Customer Experience Evaluation

Please rate your recent experience with us on a scale of 1 to 5, where:

• 5 = Excellent
• 4 = Good
• 3 = Average
• 2 = Poor
• 1 = Very Poor

Aspect of Service	Rating (1-5)
Ease of booking/placing the order	[RATING_EASE_OF_ORDER]
Speed of service / delivery time	[RATING_SPEED]
Quality of the product or service received	[RATING_QUALITY]
Professionalism and courtesy of staff	[RATING_PROFESSIONALISM]
Value for money	[RATING_VALUE]
Cleanliness and environment (if applicable)	[RATING_ENVIRONMENT]
Overall satisfaction	[RATING_OVERALL]

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3. Net Promoter Score (NPS)

On a scale of 0 to 10, how likely are you to recommend [COMPANY_NAME] to a friend, colleague, or family member?

0 (Not at all likely) — — — 10 (Extremely likely)

Your Score: [NPS_SCORE]

Reason for your score: Please briefly explain why you gave this score.

[NPS_REASON]

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4. Product and Service Specifics

Help us understand the specifics of your purchase or interaction.

Which specific features did you like the most?

• Feature A: [SPECIFIC_FEATURE_A]
• Feature B: [SPECIFIC_FEATURE_B]
• Feature C: [SPECIFIC_FEATURE_C]
• Other: [OTHER_FEATURE]

Which specific features did you dislike or find difficult to use?

[DISLIKED_FEATURES]

Did you encounter any issues during your experience?

• No issues
• Yes – Technical Issue
• Yes – Billing/Pricing Issue
• Yes – Customer Service Issue
• Yes – Product Quality Issue
• Yes – Shipping/Delivery Issue
• Other: [OTHER_ISSUE_TYPE]

If yes, please describe the issue:

[ISSUE_DESCRIPTION]

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5. Staff and Support Interaction

If you interacted with our team, please let us know how they did.

How would you rate the knowledge of the staff member assisting you?

• Very Knowledgeable
• Somewhat Knowledgeable
• Neutral
• Not Very Knowledgeable
• Not at all Knowledgeable

Did the staff member resolve your issue or answer your question completely?

• Yes, completely
• Yes, partially
• No, I need further assistance

Comments regarding the staff member (Optional):

[STAFF_COMMENTS]

Is there any specific employee you would like to recognize or commend? Employee Name: [EMPLOYEE_TO_COMMEND]

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6. Suggestions for Improvement

We are constantly striving to better serve our customers. Please share any ideas you have that could help us improve our products, services, or customer experience.

What is one thing we could do to make your experience better?

[SUGGESTION_IMPROVEMENT]

Are there any products or services you wish we offered?

[NEW_PRODUCT_SUGGESTION]

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7. Customer Loyalty & Demographics

This information helps us tailor our services to better meet your needs.

How long have you been a customer of [COMPANY_NAME]?

• Less than 6 months
• 6 months to 1 year
• 1 to 3 years
• 3 to 5 years
• More than 5 years

How often do you typically use our product/service?

• Daily
• Weekly
• Monthly
• A few times a year
• Once a year or less

How did you first hear about us?

• Search Engine (Google, Bing, etc.)
• Social Media
• Friend/Family Referral
• Advertisement
• Event/Conference
• Other: [OTHER_SOURCE]

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8. Additional Comments

Please use this space for any other feedback, complaints, or compliments that were not covered in the previous sections.

[ADDITIONAL_COMMENTS]

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9. Future Contact Consent

May we contact you regarding your feedback?

• Yes
• No

If yes, what is the preferred method of contact?

• Email
• Phone

Would you like to receive news, updates, and promotional offers from [COMPANY_NAME]?

• Yes, please sign me up for the newsletter using the email provided above.
• No, thank you.

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10. Submission & Verification

Submitted By: [CUSTOMER_SIGNATURE]

Submission Date: [SUBMISSION_DATE]

Thank you for taking the time to provide your feedback!
We appreciate your business and look forward to serving you again.

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Form ID: [FORM_ID]
Version: [FORM_VERSION]
For internal use only:

• Data Entry Operator: [DATA_ENTRY_OPERATOR]
• Status: [PROCESSING_STATUS]
• Follow-up Required: [FOLLOW_UP_REQUIRED] (Yes/No)
• Assigned Manager: [ASSIGNED_MANAGER]