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Last active August 29, 2015 13:56
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A simple form.html
<!DOCTYPE HTML>
<html>
<head>
<meta charset="utf-8">
<title> DBC Medical Exam </title>
</head>
<body>
<center>
<h2> DBC Physical Health Exam. </h2>
<p> Dear Students, it has come to our attention that many of you have been neglecting your physical well being in your persuit of learning Ruby. While we appriciate your enthusiasm health always comes first! </p>
<p> All students are to complete the exam at their <i> earlist </i> convenience. Thank You! </p>
</center>
<form action="#" method="POST" name="Cereal Consumption Pandemic">
<fieldset>
<legend> Student Information </legend>
<label for="student name"> Name: </label>
<input type="text" name="student name" id="student name">
<br /><br />
<p> In which city are you attending DBC? </p>
<br />
<input type="radio" name="city" value="San Francisco" id="San Francisco">
<label for="San Francisco"> San Francisco &nbsp;&nbsp; </label>
<input type="radio" name="city" value="Chicago" id="Chicago">
<label for="Chicago"> Chicago &nbsp;&nbsp; </label>
<input type="radio" name="city" value="New York" id="New York">
<label for="New York"> New York &nbsp;&nbsp; </label>
<br /><br /></br />
<label for="cohorts"> Which Cohort are you in? </label>
<br>
<select name="cohorts" id="cohorts">
<optgroup label="Phase 0">
<option> Dragonflies </option>
<option> Grasshoppers </option>
</optgroup>
<optgroup label="Phase 1">
<option> Otters </option>
<option> Squirels </option>
</optgroup>
<optgroup label="Phase 2">
<option> Monkeys </option>
<option> Gorillas </option>
</optgroup>
<optgroup label="Phase 3">
<option> Lions </option>
<option> Tigers </option>
</optgroup>
</select>
<br />
</fieldset>
<fieldset>
<legend> Exam Questions </legend>
<p> On average, how many hours of sleep do you get each night?</p>
<br />
<input type="radio" name="sleep" value="0 - 2" id="0 - 2">
<label for="0 - 2"> 0 - 2 &nbsp;&nbsp; </label>
<input type="radio" name="sleep" value="3 - 5" id="3 - 5">
<label for="3 - 5"> 3 - 5 &nbsp;&nbsp; </label>
<input type="radio" name="sleep" value="6 - 8" id="6 - 8">
<label for="6 - 8"> 6 - 8 &nbsp;&nbsp; </label>
<input type="radio" name="sleep" value="more than 8" id="more than 8">
<label for="more than 8"> More than 8 </label>
<br /><br />
<p> Which of the following do you eat more than twice a week? <br /><i> Please check all that apply </i></p><br />
<input type="checkbox" name="foods" value="Microwave Dinners" id="Microwave Dinners">
<label for="Microwave Dinners"> Microwave Dinners </label><br>
<input type="checkbox" name="foods" value="Apples" id="Apples">
<label for="Apples"> Apples </label><br>
<input type="checkbox" name="foods" value="Bananas" id="Bananas">
<label for="Bananas"> Bananas </label><br>
<input type="checkbox" name="foods" value="Candy" id="Candy">
<label for="Candy"> Candy </label><br>
<input type="checkbox" name="foods" value="Ham Sandwiches" id="Ham Sandwiches">
<label for="Ham Sandwiches"> Ham Sandwiches </label>
<br /><br />
<label for="essay"> Is there anything we could do to help support your physical well being? </label><br>
<textarea name="essay" id="essay" rows="10" cols="60"></textarea><br/ >
</fieldset>
<input type="submit" value="Submit">
</body>
</html>
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