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Example Survey Form

This is what this form looks like in HTML.

<!-- Special FormMail Script Fields -->

<FORM METHOD="POST" 
ACTION="PLACE THE URL FOR FORMMAIL HERE">

<input type=hidden name="subject" value="Input from Form">

<input type=hidden name="recipient" 
value="nouser@shamash.org">

<input type=hidden name="required" 
value="email,realname,Address1,City,State,Phone Number,Zip">

<input type=hidden name="print_config" value="email,realname">

<!--
<input type=hidden name="sort" value="order:realname,email,Address1,City,State,
Zip,Phone Number,Comments">             


<input type=hidden name="redirect" value="thanks.html">
-->

<!-- Your Fields -->

<H6>Note: You need to fill in all the address fields.</H6>

<P>Your Name:
<INPUT TYPE="text" NAME="realname" SIZE=40 MAXLENGTH=80>

<P>Your EMail Address: 
<INPUT TYPE="text" NAME="email" SIZE=40 MAXLENGTH=100>
 
<P>Your Address:
<INPUT TYPE="text" NAME="Address1" SIZE=60 MAXLENGTH=80>

<P>City:
<INPUT TYPE="text" NAME="City"  SIZE=20 MAXLENGTH=20>

State:
<INPUT TYPE="text" NAME="State" SIZE=3 MAXLENGTH=2> 

Zip:
<INPUT TYPE="text" NAME="Zip"  SIZE=5 MAXLENGTH=10> 

Phone Number: 
<INPUT TYPE="text" NAME="Phone Number" VALUE="(XXX) XXX-XXXX" 
SIZE=14 MAXLENGTH=20>

<P>Age:
<SELECT NAME="Age">
<OPTION>12 or under
<OPTION>13-21
<OPTION>22-34
<OPTION>35-44
<OPTION>45-54
<OPTION>55-64
<OPTION>65 or over
</SELECT>

Gender:
<INPUT TYPE="radio" NAME="Gender" VALUE="Male">Male
<INPUT TYPE="radio" NAME="Gender" VALUE="Female">Female

<P>What is your religious denomination (choose as many as apply):
<SELECT NAME="Denomination" MULTIPLE SIZE=8>
<OPTION>Orthodox
<OPTION>Traditional
<OPTION>Conservative
<OPTION>Reconstructionist
<OPTION>Reform
<OPTION>Humanistic
<OPTION>Secular
<OPTION>Unaffiliated
<OPTION SELECTED>Unsure
</SELECT>

<P>How should I contact you (check all that apply):
<dl>
<dt><INPUT TYPE="checkbox" NAME="Respond" VALUE="callme">Call me
<dt><INPUT TYPE="checkbox" NAME="Respond" VALUE="mailme">Mail me some information
<dt><INPUT TYPE="checkbox" NAME="Respond" VALUE="emailme">Email me 
</dl>

<p>Please select a  password: 
<INPUT TYPE="password" NAME="password"> 

<P>Please Place your comments here:
<TEXTAREA NAME="Comments"  COLS=50 ROWS=4></TEXTAREA>

<INPUT TYPE="submit" VALUE="Mail this Information">
<INPUT TYPE="reset" VALUE="Reset this form">

</FORM>

This page has been viewed times since January 1, 1997.
Documentation adapted by: David Rosenthal and Matthew Barr

Last modified: Thursday, 02-Oct-2003 13:07:55 EDT

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