document.write('
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  1. <!DOCTYPE html>
  2. <html lang="en">
  3.  
  4. <head>
  5.     <meta charset="UTF-8">
  6.     <meta http-equiv="X-UA-Compatible" content="IE=edge">
  7.     <meta name="viewport" content="width=device-width, initial-scale=1.0">
  8.     <title>Form Validasi Mahasiswa FTEIC</title>
  9.     <link rel="stylesheet" href="https://maxcdn.bootstrapcdn.com/bootstrap/4.5.2/css/bootstrap.min.css">
  10.     <script src="main.js"></script>
  11.     <link rel="stylesheet" href="style.css">
  12. </head>
  13.  
  14. <body background="header.jpg">
  15.     <header>
  16.         <h5>Institut Teknologi Sepuluh Nopember Surabaya</h5>
  17.     </header>
  18.  
  19.     <br>
  20.     <div class="container">
  21.         <div class="tittle">
  22.             <h2>Formulir Validasi Vaksin Covid-19</h2>
  23.         </div>
  24.         <form name="formValidasi" onsubmit="return validateForm()" class="pt-2">
  25.             <div class="form-group">
  26.                 <label style="color: white;" class="font-weight-bold">Nama</label>
  27.                 <input type="text" name="nama" placeholder="Nama lengkap" class="form-control" minlength="5" maxlength="50">
  28.             </div>
  29.  
  30.             <div class="form-group">
  31.                 <label style="color: white;" class="font-weight-bold">NRP</label>
  32.                 <input type="text" name="nrp" placeholder="NRP lengkap" class="form-control" minlength="8"
  33.                  maxlength="16">
  34.             </div>
  35.  
  36.             <div class="form-group">
  37.                 <label style="color: white;" class="font-weight-bold">Email</label>
  38.                 <input type="email" name="email" placeholder="Email aktif" class="form-control">
  39.             </div>
  40.  
  41.             <div class="form-group">
  42.                 <label style="color: white;" class="font-weight-bold">Jurusan</label>
  43.                 <select name="jurusan" class="form-control">
  44.                     <option selected>- Pilih Jurusan</option>
  45.                     <option value="1">Teknik Elektro</option>
  46.                     <option value="2">Teknik Biomedik</option>
  47.                     <option value="3">Teknik Komputer</option>
  48.                     <option value="4">Teknik Informatika</option>
  49.                     <option value="5">Sistem Informasi</option>
  50.                     <option value="6">Teknologi Informasi</option>
  51.                 </select>
  52.             </div>
  53.  
  54.             <div class="form-group">
  55.                 <label style="color: white;" class="font-weight-bold">Apakah sudah vaksin Covid-19?</label>
  56.                 <select name="status_vaksin" class="form-control">
  57.                     <option selected>- Pilih Status Vaksin</option>
  58.                     <option value="1">Belum</option>
  59.                     <option value="2">Sudah - Dosis 1</option>
  60.                     <option value="3">Sudah - Dosis 2</option>
  61.                 </select>
  62.             </div>
  63.  
  64.             <div class="form-group">
  65.                 <label style="color: white;" class="font-weight-bold">Alamat Domisili</label>
  66.                 <textarea type="text" name="domisili" id="" cols="30" rows="3" placeholder="Alamat lengkap" class="form-control"></textarea>
  67.             </div>
  68.  
  69.             <button type="submit" class="btn btn-primary" style="margin-top: 10px;">Submit</button>
  70.         </form>
  71.     </div>
  72.  
  73.     <br>
  74.     <footer>
  75.         <table>
  76.             <td>&copy; Dewi Mardani C - PWEB A 2021</td>
  77.         </table>
  78.     </footer>
  79. </body>
  80.  
  81. </html>
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