\documentclass{article}
\usepackage{fullpage}
\title{Review of\\
$\mathit{\langle Title~of~Presentation\rangle}$\\
Presented by\\
$\mathit{\langle Name~of~Speaker\rangle}$\\
to CS501\\
$\mathit{\langle Date~of~Presentation\rangle}$
}
\author{$\mathit{\langle Name\rangle}$\\
Department of Computer Science and Engineering\\
State University of New York at Buffalo\\
226 Bell Hall\\
Buffalo, NY 14260-2000\\
$\mathit{\langle login\rangle}$\texttt{@cs.buffalo.edu}}
\date{$\mathit{\langle date~of~review\rangle}$}
\begin{document}
\maketitle
\section{Summary}
\textit{Give a short summary of the presentation in your own words, to
the best of your ability.}
\section{Reaction}
\textit{Briefly describe your reaction to/impression of the
presentation. How interesting do you find the research area as a
potential area for your own future work?}
\pagebreak
\begin{center}\Large
Anonymous Feedback to\\
$\mathit{\langle Name~of~Speaker\rangle}$\\
on your Presentation to CS501 of\\
$\mathit{\langle Date~of~Presentation\rangle}$
\vspace{2ex}
Critique of Contents
\vspace{2ex}
Critique of Style
\end{center}
\end{document}