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<?php

  //Check if the form has been posted
    if(isset($_POST["form_posted"]) && $_POST["form_posted"] == "true") {
      //Get posted details
        $name = $_POST["name"];
        $code = $_POST["code"];
        $ip = $_SERVER["REMOTE_ADDR"];
        $time = date('Y/m/d - H:i');

        //Validate the information
          if($name == 0 || $code == 0) {
            $message =  "Please enter all details";
          }

    //All info has been posted
    //Store into the database
    //Database should have the following fields/settings:
      //number INT NOT NULL AUTO_INCREMENT
      //PRIMARY KEY(number)
      //name TEXT NOT NULL
      //code TEXT NOT NULL
      //ip TEXT NOT NULL
      //time TEXT NOT NULL

      //Database settings
        $server = "server";
        $database = "se";
        $table = "example";
        $username = "eusername";
        $password = "password";

      //Insert the new info
        //Connect to server
          $connect = "mysql_connect($server, $username, $password)";
            if(!$connect) die(mysql_error());

        //Connect to the database
          mysql_select_db($database, mysql_connect($server, $username, $password)) or die(mysql_error());

        //Insert new data
          mysql_query("INSERT INTO $table (name, code, ip, time) VALUES ('".mysql_real_escape_string($name)."', '".mysql_real_escape_string($code)."', '$ip', '$time')") or die (mysql_error());

      //Information has been entered
        $message = "Success!";

  }

?>
<html>
  <head>

    <title>
      Page title
    </title>

  </head>
  <body>

    <style type="text/css">

      .FormContainer {
        font-family:arial;
      }

      .FormContainer .Message {
        display:<?php if(isset($message)) echo "block"; else echo "none"; ?>;
        padding:5px;
        border-width:1px;
        border-style:solid;
        border-color:#2F74D0;
        background-color:#CEF0FF;
        text-align:center;
        font-weight:bold;
      }

      .FormContainer td {
        padding-top:10px;
      }

    </style>

    <table class="FormContainer">
      <form action="#" method="post">
        <input type="hidden" name="form_posted" value="true" />
        <tr>
          <td class="Message" colspan="2">
            <?php
              if(isset($message)) {
                echo $message;
              }
            ?>
          </td>
        </tr>
        <tr>
          <td>
            Name
          </td>
          <td>
            <input type="text" name="name" <?php if(isset($name)) echo "value=\"".$name."\""; ?> />
          </td>
        </tr>
        <tr>
          <td>
            Code
          </td>
          <td>
            <textarea name="code" rows="5" cols="17"><?php if(isset($code)) echo $code; ?></textarea>
          </td>
        </tr>
        <tr>
          <td>
            <input type="reset" value="Reset" />
          </td>
          <td>
            <input type="submit" value="Submit" />
          </td>
        </tr>
      </form>
    </table>

  </body>
</html>