Feedback Form

Name(Required)

First Last

Email(Required)

Title(Required)

Restaurant/Company Name(Required)

Address

Restaurant website or Yelp/Google Business page

Links to social media profiles (personal or restaurant) or handles.

Distributor Name

Other

Tell us about your experience with the Jurgielewicz farm and products.

Are you a current JJS customer?

Yes

Would you be interested in our marketing team reaching out for cross-promotional opportunities?(Required)

Yes

What duck products are you most interested in?

Do you currently serve duck on your menu?

Yes

Which duck brand do you use?

Other Brand

Are you interested in receiving samples or having a representative from the farm reach out to you?

Yes

Please share the event date, products requested and estimated quantity if known.

Title