Welcome to the Roundy's Customer Satisfaction Survey.

We value your candid feedback and appreciate you taking the time to complete our survey.

Please fill in the following information from your receipt.

Date:

-- 010203040506070809101112 / -- 01020304050607080910111213141516171819202122232425262728293031 / -- 1718

Time:

-- 010203040506070809101112 : -- 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859   -- AMPM

Store Number (4-digits):

Lane Number (2-digits):

Transaction Number (4-digits):

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