Customer Feedback Form Template

A Customer Feedback Form is a valuable tool for gathering insights and feedback from your customers, helping you improve your products or services. Here’s a template for a basic Customer Feedback Form that you can use for your small business:

Customer Feedback Form Template

[Company Name] Customer Feedback Form

Date: [Date]

Customer Information:

  • Name: [Customer Name]
  • Email: [Customer Email]
  • Phone: [Customer Phone]

Order/Transaction Information:

  • Order/Transaction Number: [Order/Transaction Number]
  • Date of Purchase: [Date of Purchase]


Please rate your experience on a scale of 1 to 5, with 1 being the lowest and 5 being the highest.

  1. Product/Service Quality: (1-5)
    [Rating Scale]
  2. Customer Service: (1-5)
    [Rating Scale]
  3. Delivery/Shipping: (1-5)
    [Rating Scale]
  4. Website/Online Experience: (1-5)
    [Rating Scale]

Comments and Suggestions:

Please share your thoughts, comments, or suggestions regarding your experience with us. Your feedback is invaluable in helping us improve.

[Open Text Box]

Would You Recommend Us?

  • [ ] Yes
  • [ ] No

Additional Feedback:

Is there anything else you’d like to add or any specific aspects of your experience you’d like to highlight?

[Open Text Box]

Consent for Testimonial:

  • [ ] Yes, I consent to having my feedback used as a testimonial.
  • [ ] No, I do not wish for my feedback to be used as a testimonial.

Contact Preference:

If you would like us to follow up with you regarding your feedback, please select your preferred method of contact:

  • [ ] Email
  • [ ] Phone
  • [ ] No follow-up needed

Submit Your Feedback:

[Submit Button]


  • Customize the form with your company’s name and logo.
  • Adjust the rating scales and questions based on your specific business and industry.
  • Provide an option for customers to share their comments, suggestions, and testimonials.
  • Ensure that the form is user-friendly and mobile-responsive for ease of use.
  • Include a mechanism for securely storing and analyzing the feedback received.