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Rainrix2001

Form

Rainrix2001
Aug 21st, 2019
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  1. <!DOCTYPE html>
  2. <html>
  3. <head>
  4.     <title>HTML Form</title>
  5. </head>
  6. <body>
  7.     <form action="/action_page.php" target="_top" method="post">
  8.         <fieldset>
  9.             <legend><h2>Client Information Sheets</h2></legend>
  10.  
  11.   Name:<br>
  12.   <input type="text" placeholder="First Name, Middle Name, Last Name" name="yourname" size="40">
  13.   <br><br>
  14.   Address:<br>
  15.   <input type="text" placeholder="Address" name="address" size="40">
  16.   <br><br>
  17.   Birthday:<br>
  18.   <select name="month">
  19.   <option value="month">Month</option>
  20.   <option value="month">Jan</option>
  21.   <option value="month">Feb</option>
  22.   <option value="month">Mar</option>
  23.   <option value="month">Apr</option>
  24.   <option value="month">May</option>
  25.   <option value="month">Jun</option>
  26.   <option value="month">Jul</option>
  27.   <option value="month">Aug</option>
  28.   <option value="month">Sep</option>
  29.   <option value="month">Oct</option>
  30.   <option value="month">Nov</option>
  31.   <option value="month">Dec</option>
  32. </select>
  33.     <select name="days">
  34.     <option value="days">Day</option>
  35.     <option value="days">1</option>
  36.     <option value="days">2</option>
  37.     <option value="days">3</option>
  38.     <option value="days">4</option>
  39.     <option value="days">5</option>
  40.     <option value="days">6</option>
  41.     <option value="days">7</option>
  42.     <option value="days">8</option>
  43.     <option value="days">9</option>
  44.     <option value="days">10</option>
  45.     <option value="days">11</option>
  46.     <option value="days">12</option>
  47.     <option value="days">13</option>
  48.     <option value="days">14</option>
  49.     <option value="days">15</option>
  50.     <option value="days">16</option>
  51.     <option value="days">17</option>
  52.     <option value="days">18</option>
  53.     <option value="days">19</option>
  54.     <option value="days">20</option>
  55.     <option value="days">21</option>
  56.     <option value="days">22</option>
  57.     <option value="days">23</option>
  58.     <option value="days">24</option>
  59.     <option value="days">25</option>
  60.     <option value="days">26</option>
  61.     <option value="days">27</option>
  62.     <option value="days">28</option>
  63.     <option value="days">29</option>
  64.     <option value="days">30</option>
  65.     <option value="days">31</option>
  66. </select>
  67.     <select name="years">
  68.     <option value="years">Year</option>
  69.     <option value="years">1980</option>
  70.     <option value="years">1981</option>
  71.     <option value="years">1982</option>
  72.     <option value="years">1983</option>
  73.     <option value="years">1984</option>
  74.     <option value="years">1985</option>
  75.     <option value="years">1986</option>
  76.     <option value="years">1987</option>
  77.     <option value="years">1988</option>
  78.     <option value="years">1989</option>
  79.     <option value="years">1990</option>
  80.     <option value="years">1991</option>
  81.     <option value="years">1992</option>
  82.     <option value="years">1993</option>
  83.     <option value="years">1994</option>
  84.     <option value="years">1995</option>
  85.     <option value="years">1996</option>
  86.     <option value="years">1997</option>
  87.     <option value="years">1998</option>
  88.     <option value="years">1999</option>
  89.     <option value="years">2000</option>
  90.     <option value="years">2001</option>
  91.     <option value="years">2002</option>
  92.     <option value="years">2003</option>
  93.     <option value="years">2004</option>
  94.     <option value="years">2005</option>
  95.     <option value="years">2006</option>
  96. </select><br><br>
  97.     Age:
  98.   <input type="text" name="age" size="5">
  99.   <br><br>
  100.  
  101.   Gender:<br>
  102.   <input type="radio" name="gender">Male &nbsp
  103.  <input type="radio" name="gender">Female &nbsp
  104.  <br><br>
  105.  
  106.  Email:<br>
  107.     <input type="mail" placeholder="Email Address" name="mail" size="40">
  108.     <br><br>
  109.  
  110.  Mobile Number:<br>
  111.      <input type="phone" placeholder="Mobile Number" name="Number">
  112.      <br><br>
  113.  
  114.  Social Media Account: (Select one or more)<br>
  115.         &nbsp &nbsp &nbsp &nbsp &nbsp
  116.         <input type="checkbox" name="facebook"> Facebook
  117.         <input type="checkbox" name="twitter"> Twitter
  118.         <input type="checkbox" name="Instagram"> Instagram
  119.         <input type="checkbox" name="Snapchat"> Snapchat
  120.         <input type="checkbox" name="Other"> Other
  121.         <br><br>
  122.  
  123. Browser Currently Using: <br>
  124.         &nbsp &nbsp
  125.         <select name="Browser">
  126.         <option value="browser">Select</option>
  127.         <option value="browser">Firefox</option>
  128.         <option value="browser">Internet Explorer</option>
  129.         <option value="browser">Safari</option>
  130.         <option value="browser">Google Chrome</option>
  131.         <option value="browser">Opera</option>
  132.         <option value="browser">Edge</option>
  133.         <option value="browser">Other</option>
  134.         </select><br><br>
  135.  
  136.         Rate my Site:
  137.     &nbsp &nbsp
  138.     <select name="Rate">
  139.         <option value="0">0</option>
  140.         <option value="1">1</option>
  141.         <option value="2">2</option>
  142.         <option value="3">3</option>
  143.         <option value="4">4</option>
  144.         <option value="5">5</option>
  145.         <option value="6">6</option>
  146.         <option value="7">7</option>
  147.         <option value="8">8</option>
  148.         <option value="9">9</option>
  149.         <option value="10">10</option>
  150.     </select><br><br>
  151.  
  152.     Comment and Suggestion: <br>
  153.     &nbsp &nbsp; &nbsp; &nbsp; &nbsp;
  154.     <textarea name="comment" rows="5" cols="40" placeholder="Write your Comment and Suggestion here..."></textarea><br><br>
  155.     &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;
  156.     <input type="submit" value="Submit">
  157.     <input type="reset" value="Clear">
  158.  
  159. </fieldset>
  160. </form>
  161. </body>
  162. </html>
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