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44 lines (44 loc) · 2.04 KB
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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<title>Register With Us</title>
</head>
<body>
<!--<form method="POST" action="https://request-inspector.glitch.me/">-->
<form method="POST" action="https://www.elformo.com/forms/6e773282-a76f-4f7d-8521-188c33b8aa68">
<section>
<div>
<label for="email_address" type="email">Email Address:</label>
<input type="text" name="email_address" id="email_address" placeholder="please enter your email address here"><br>
</div>
<div>
<label for="password" type="password">Password:</label>
<input type="password" name="password" id="password" placeholder="please enter your password here"><br><br>
</div>
<textarea name="bio" id="bio" cols="30" rows="10" placeholder="please put a short description of yourself here"></textarea><br>
<div>
<button type="submit">Submit</button>
</div>
</section>
<section id="q1">
<p>How did you hear about us?</p>
<!-- <p for="q1_1;q1_2;q1_3;q1_4">How did you hear about us?</p>-->
<label for="q1_1"><input type="checkbox" name="referred[]" id="q1_1" value="billboard">Billboard</label><br>
<label for="q1_2"><input type="checkbox" name="referred[]" id="q1_2" value="radio advertisement">Radio Advertisement</label><br>
<label for="q1_3"><input type="checkbox" name="referred[]" id="q1_3" value="internet advertisement">Internet Advertisement</label><br>
<label for="q1_4"><input type="checkbox" name="referred[]" id="q1_4" value="other">Other</label><br><br>
</section>
<section>
<label for="browser">What web browser are you using?</label><br>
<select name="browerchoice" id="browser">
<option value="chrome">Chrome</option>
<option value="safari">Safari</option>
<option value="firefox">Firefox</option>
<option value="other">Other</option>
</select><br>
<button type="submit">Submit</button>
</section>
</form>
</body>
</html>