<form action="http://www.i-55.com/cgi-bin/public_mail.pl"
method="post">
<input type="hidden" name="recipient"
value="youremail@i-55.com" >
<input type="hidden" name="subject"
value="Customer Feedback Form">
What kind of comment would you like to send?<br><br>
<input type="radio" name="MessageType"
value="Problem">Problem
<input type="radio" checked name="MessageType"
value="Suggestion">Suggestion
<input type="radio" name="MessageType"
value="Praise">Praise<br><br>
What about us do you want to comment on?<br>
<select name="Subject" size="1">
<option selected>Web Site</option>
<option>Company</option>
<option value="Services">Services</option>
<option>Employee</option>
<option>(Other)</option></select>
Other: <input type="text" size="26"
maxlength="256" name="SubjectOther"><br><br>
Enter your comments in the space provided below:<br>
<textarea name="Comments" rows="5"
cols="42"></textarea><br><br>
Tell us how to get in touch with you:<br><br>
Name<input type="text" size="35"
maxlength="256" name="realname"><br><br>
E-mail<input type="text" size="35"
maxlength="256" name="UserEmail"><br><br>
Telephone<input type="text" size="35"
maxlength="256" name="UserTel"><br><br>
FAX<input type="text" size="35"
maxlength="256" name="UserFAX"><br><br>
<input type="checkbox" name="ContactRequested"
value="ContactRequested">
Please contact me as soon as possible regarding this matter.<br><br>
<input type="submit" value="Submit Comments">
<input type="reset" value="Clear Form">
</form> |
