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- <!DOCTYPE html>
- <html>
- <head>
- <meta charset="utf-8">
- <title>Web Form</title>
- <link rel="stylesheet" type="text/css" href="form.css">
- </head>
- <h1>NerdLand Order Form</h1>
- <form action="/action_page.php">
- <fieldset>
- <legend>Personal Information:</legend>
- First Name:<br>
- <input type="text" name="firstname" value=""> (required)
- <br><br>
- Last Name:<br>
- <input type="text" name="lastname" value=""> (required)
- <br><br>
- Street Address:<br>
- <input type="text" name="streetaddress" value=""> (required)
- <br><br>
- City:<br>
- <input type="text" name="city" value=""> (required)
- <br><br>
- State:<br>
- <input type="text" name="state" value=""> (required)
- <br><br>
- Zip Code:<br>
- <input type="text" name="zipcode" value="" pattern="[0-9]{5}" title="five digit zip code"> (required)
- <br><br>
- Phone Number:<br>
- <input type="text" name="phonenumber" value="" pattern="[0-9]{10}" title="ten digit phone number"> (optional)
- <br><br>
- Email Address:<br>
- <input type="text" name="emailaddress" value=""> (required)
- <br><br>
- Credit Card Number:<br>
- <input type="text" name="creditcardnumber" value="xxxx"> - <input type="text" name="creditcardnumber" value="xxxxxx"> - <input type="text" name="creditcardnumber" value="xxxxx"> (required)
- </fieldset>
- <br><br>
- <fieldset>
- <legend>Product Options:</legend>
- Select a Product:<br>
- <select name="products">
- <option value="Plush">Pokemon Center Original Stuffed Litten Plush ($21.54)</option>
- <option value="Plush2">Pokemon Center Original Stuffed Rowlet Plush ($27.94)</option>
- <option value="Plush3">Pokemon Center Original Stuffed Popplio Plush ($21.99)</option>
- <option value="Plush4">Pokemon Center Original Stuffed Rockruff Plush ($35.99)</option>
- </select> (required)
- <br><br>
- Quantity of Product:<br>
- <select name="products">
- <option value="number1">1</option>
- <option value="number2">2</option>
- <option value="number3">3</option>
- <option value="number4">4</option>
- <option value="number5">5</option>
- <option value="number6">6</option>
- <option value="number7">7</option>
- <option value="number8">8</option>
- <option value="number9">9</option>
- <option value="number10">10</option>
- </select> (required)
- <br><br>
- Would You Like Priority Shipping? (optional)<br>
- <input type="checkbox" name="priorityshipping" value="Yes">Yes!<br>
- <br>
- Would You Like to Be Added To Our Mailing List? (required) <br><br>
- <input type="radio" name="option" value="yes"> Yes, I Want to Be Added to The Mailing List!<br>
- <input type="radio" name="option" value="no"> No, I Don't Want to Be Added to The Mailing List.<br>
- </fieldset>
- <br><br>
- <input type="submit" value="Submit">
- </form>
- </body>
- </html>
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