my own evaluation form?

I am a fairly new agency RN. A couple of months ago my agency was submitting me to a new facility. The recruiter asked me for the name for the nurse manager of the unit where I usually work. Well, I rarely see the nurse manager, more often see the charge nurse of the day, but cannot for the life of me remember her last name. I am sure they don't remember my name- unless I have been there several times- So I thought it would be nice to have "proof" that I do a good job with a positive attitude. I would like to make my own evaluation form and ask each charge nurse to fill it out at the end of my shift. (probably not every single day, but every so often I don't want to be a PITA) Mostly so when I go to a new position I have something to "show " a new prospective employer.

Does anyone have one they can share? I could make it up, but thought I would save a wee bit of time... Or any ideas on "specifics " to evaluate? Thanks!