This template is designed to be versatile and applicable to various industries, from retail and hospitality to digital services. It focuses on the four pillars of service: Professionalism, Efficiency, Resolution, and Personalization.
Customer Name
Date of Interaction
Interaction Channel
In-Person
Phone
Email/Support Ticket
Live Chat/Social Media
Representative Name (if known)
Please rate the following statements on a scale of 1 to 5. (1 = Strongly Disagree, 5 = Strongly Agree)
1 | 2 | 3 | 4 | 5 | |
|---|---|---|---|---|---|
The representative was friendly and polite. | |||||
The representative listened to my needs without interruption. | |||||
My inquiry was handled in a timely manner. | |||||
The representative was knowledgeable about the product/service. | |||||
The representative communicated clearly and effectively. |
Was your issue resolved during this interaction?
Yes, completely.
Partially (Follow-up required).
No, it remains unresolved.
How much effort did you personally have to put forth to handle your request?
Very Low Effort
Moderate Effort
High Effort
Overall, how satisfied are you with the service you received?
Very Dissatisfied
Dissatisfied
Neutral
Satisfied
Very Satisfied
Based on this experience, how likely are you to recommend us to others? (0 = Not at all likely, 10 = Extremely likely)
What did the representative do particularly well? (e.g., empathy, technical skill, speed)
What is one thing we could have done differently to improve your experience?
Any additional comments or shout-outs?
Form Template Insights
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To provide a deeper understanding of why this template works, we must look at the mechanics of customer feedback.
The form is organized to move from objective facts to subjective feelings. By asking for the "Interaction Channel" and "Date" first, you anchor the customer’s memory to a specific event before asking them to evaluate performance. This reduces the risk of "generalized venting" and keeps the feedback focused on a single moment in time.
Each section of the form targets a specific metric used by top-tier service organizations:
The use of a 1–5 scale (known as a Likert Scale) is intentional.
A template that only uses checkboxes provides numbers without context. A template that only uses text boxes provides context that is too difficult to measure.
This is the most critical checkpoint. By separating Resolution from Satisfaction, you can identify "Polite Failures."
Example: A customer might rate the staff member a "5" for friendliness but a "1" for resolution. This tells you that your staff has great people skills, but your internal systems or authorities are preventing them from actually helping the customer.
The value of the form isn't just in the collection of data, but in the response to it. When using this template:
Mandatory Questions Recommendation
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Here are the essential questions and the reasoning behind them:
Question: "Was your issue resolved during this interaction?"
Why it’s mandatory: This is the ultimate metric for customer support. A representative can be the friendliest person in the world, but if the customer's problem remains unsolved, the service has failed its primary objective.
The Insight: It allows you to calculate your First Contact Resolution (FCR) rate. High FCR is the strongest driver of customer satisfaction and reduces the cost of "callback" volume.
Question: "Overall, how satisfied are you with the service you received?"
Why it’s mandatory: This provides a single, high-level data point that summarizes the user’s emotional state. It is the industry standard for benchmarking.
The Insight: It acts as a "temperature check." If a customer gives high marks for "Friendliness" but a low mark for "Overall Satisfaction," it signals that your processes (like wait times or policies) might be the problem, rather than the staff.
Question: "The representative was knowledgeable and professional." (Likert Scale)
Why it’s mandatory: You need to distinguish between the person and the product. Sometimes a customer is unhappy because the product broke, but they were impressed by the person who helped them.
The Insight: This is your primary tool for staff coaching. It helps you identify which team members are ambassadors for your brand and which may need more technical training or soft-skills development.
Question: "What is one thing we could have done differently?" OR "Additional Comments."
Why it’s mandatory: Data tells you what is happening; comments tell you why. A "3 out of 5" rating is ambiguous, but a comment explaining that "the music on hold was too loud" provides a specific, fixable action.
The Insight: This often reveals "blind spots" that you didn't think to ask about in the multiple-choice section. It gives the customer a voice, which in itself can improve their perception of your brand.
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