<form method="POST">
                <div class="form-group row">
                    <label class="col-2 col-form-label">Nama</label>
                    <div class="col-10">
                        <input type="text" name="nama" class="form-control" value="">
                    </div>
                </div>
                <div class="form-group row">
                    <label class="col-2 col-form-label">No. K/P</label>
                    <div class="col-10">
                        <input type="text" name="no_kp" class="form-control" value="">
                    </div>
                </div>
                <div class="form-group row">
                    <label class="col-2 col-form-label">Jabatan Dilawat</label>
                    <div class="col-10">
                        <select name="jabatan_dilawat" class="form-control">
                            <option value="Fakulti Perubatan">Fakulti Perubatan</option>
                            <option value="Pusat Asasi">Pusat Asasi</option>
                            <option value="Pejabat Pendaftar">Pejabat Pendaftar</option>
                        </select>
                    </div>
                </div>
                <div class="form-group row">
                    <label class="col-2 col-form-label">Tujuan Lawatan</label>
                    <div class="col-10">
                        <textarea name="tujuan_lawatan" class="form-control"></textarea>
                    </div>
                </div>
                <div class="form-group row">
                    <div class="col-10 offset-2">
                        <button type="submit" class="btn btn-success">Simpan</button>
                        <button type="reset" class="btn btn-light">Set Semula</button>
                    </div>
                </div>
            </form>