Simply replace the unfilled areas such as "" and "[date]" with your information.
Dear [human resources manager or supervisor's boss],
I would like to make a formal, written complaint regarding the evaluation I received on [date] from [name of evaluator]. I fell like the evaluation was inaccurate and did not present my work in a fair context. I feel that there were inaccuracies specifically in the sections regarding [list sections/areas of inaccuracy], and feel like my evaluator did not do a complete job in reviewing my past work when writing this evaluation.
I would like to ask that you do a secondary review of this evaluation and take into account my actual work. I feel like the outcome may be quite different.
Thank you in advance for taking the time to review my concerns.