* Which range best describes your age?
* How far do you normally travel to dine out?
* How frequently do you typically dine out?
* How much do you typically spend on dinner for two?
* What prompted you to dine with us?
* When was the last time your visited our restaurant?
* What is the main reason for selecting a restaurant?
* What is your favorite restaurant in town and why?
* How likely is it that you would recommend our restaurant to a friend?
* Additional Comments
* Your Name
* Email Address (so we can contact you)