form.php

<style>
  textarea{
   vertical-align: middle;
   display:inline-block;
   position:relative;
  }
  label{
    font-weight: bold;
    color:#00CCCC;
  }
  .name{
    margin-left:2.2em;
    margin-bottom:10px;
  }
  .email{
  margin-left:5em;
  margin-bottom:10px;
  }
  .birth{
    margin-left:3.5em;
    margin-bottom:10px;
  }
  .testi{
    margin-left:2em;
    margin-bottom:20px;
  }
  .btn {
    background: #3498db;
    background-image: -webkit-linear-gradient(top, #3498db, #2980b9);
    background-image: -moz-linear-gradient(top, #3498db, #2980b9);
    background-image: -ms-linear-gradient(top, #3498db, #2980b9);
    background-image: -o-linear-gradient(top, #3498db, #2980b9);
    background-image: linear-gradient(to bottom, #3498db, #2980b9);
    -webkit-border-radius: 28;
    -moz-border-radius: 28;
    border-radius: 28px;
    text-shadow: 7px 9px 5px #71b7ed;
    font-family: Arial;
    color: #ffffff;
    font-size: 10px;
    padding: 10px 20px 10px 20px;
    text-decoration: none;
    margin-left:30em;
  }

  .btn:hover {
    background: #3cb0fd;
    background-image: -webkit-linear-gradient(top, #3cb0fd, #3498db);
    background-image: -moz-linear-gradient(top, #3cb0fd, #3498db);
    background-image: -ms-linear-gradient(top, #3cb0fd, #3498db);
    background-image: -o-linear-gradient(top, #3cb0fd, #3498db);
    background-image: linear-gradient(to bottom, #3cb0fd, #3498db);
    text-decoration: none;
  }
  </style>

 <? $bln=array("Januari","Februari","Maret","April","Mei","Juni","Juli","Agustus","September","Oktober","November","Desember");
          foreach($bln as $_X){?><option value="<?=$_X;?>"><?=$_X;?></option?><?}?></select>&nbsp;
          <select name="thn">
              <? $thn=1960; do{?><option value="<?=$thn;?>"><?=$thn;?></option><?$thn++;}while($thn <= 2000);?></select><br/>