A lot of sample forms are available on the internet. Moreover, on this forum also the forms are available. Just look at the right side on your screen. You can download any one of them.
By the way, interviewer "evaluates" the job candidate during the job interview and he/she does not give "feedback" to the candidate. Therefore, the right heading for the form should be "Interview Evaluation Form" or "Interview Assessment Form".
From India, Bangalore