<form name="form1" method="post" action="simpandana.php">

  <table width="30%" border="1" align="center">
    <tr>
      <td width="43%">No KK </td>
      <td width="57%">
     <Select name="nik" id="nik">
        <?php

                include "conn.php";
       $query = mysql_query("select * from penduduk");
       while($row = mysql_fetch_array($query))
          {
          echo "<option value='".$row['nik']."' data-alamat='".$row['alamat']."' data-nama='".$row['nama']."'>".$row['nik']."</option>";
           }

        ?>
        </select>

      </td>

    </tr>
    <tr>
      <td width="43%">Nama Kepala Keluarga </td>
      <td width="57%"><label>
        <input type="text" id="nama">
      </label></td>
    </tr>
    <tr>
      <td>Alamat </td>
      <td><label>
        <input type="text" id="alamat">
      </label></td>
    </tr>
    <tr>
      <td>Jenis Iuran </td>
      <td><label>
        <select name="t4" id="t4">
          <option value="Sumbangan">Sumbangan</option>
          <option value="Sukarela">Sukarela</option>
          <option value="Dll">Dll</option>
        </select>
      </label></td>
    </tr>
     <tr>
      <td>Bulan </td>
      <td><label>
        <select name="t5" id="t5">
          <option value="Januari">Januari</option>
          <option value="Febuari">Februari</option>
          <option value="Maret">Maret</option>
          <option value="April">April</option>
          <option value="Mei">Mei</option>
          <option value="Juni">Juni</option>
          <option value="Juli">Juli</option>
          <option value="Agustus">Agustus</option>
          <option value="September">September</option>
          <option value="Oktober">Oktober</option>
          <option value="November">November</option>
          <option value="Desember">Desember</option>
        </select>
      </label></td>
    </tr>
     <tr>
      <td>Tahun </td>
      <td> <select name="thn" id="thn">
                            <option selected="selected">Tahun</option>
                            <?php
                           for($thn=2000; $thn<=2099; $thn++){
                           echo"<option value=$thn> $thn </option>";
                            }
                            ?>
                            </select></td>
    </tr>
    <tr>
      <td>Jumlah</td>
      <td><label>
        <input name="t4" type="text" id="t4" />
      </label></td>
    </tr>
    <tr>
      <td><a href="menu.php">Back</a></td>
      <td><label>
        <input name="Simpan" type="submit" id="Simpan" value="Simpan" />
      </label>
        <label>
        <input name="Cancel" type="reset" id="Cancel" value="Cancel" />
      </label></td>
    </tr>
  </table>
</form>
    </tr>
  </table>
</form>
<script>
        $(document).ready(function(){
    $("#nik").change(function(){
       var nama = $("#nik :selected").attr('data-nama');
        $("#nama").val(nama);
    });
});
</script>