<html>
<head>
<title>Simple Survey</title>
</head>
<body>
<h3>Please fill out my Survey</h3>
<form method="post" enctype="multipart/form-data" action="http://pub17.bravenet.com/emailfwd/senddata.php" accept-charset="utf-8">
<input type="hidden" name="usernum" value="xxxxxxxxxx">
<input type="hidden" name="cpv" value="2">
<!-- DO NOT CHANGE OR REMOVE THE 3 TAGS ABOVE THIS COMMENT-->
Setting up radio buttons
1) How old are you ?
Under 18 years old
Between 18-24 years old
Between 25-34 years old
Between 35-44 years old
More than 44 years old
<dl>
<dt> 1) How old are you?</dt>
<dd><input type="radio" name="Age" value="-18">Under 18 years old</dd>
<dd><input type="radio" name="Age" value="18-24">Between 18 and 24 years old</dd>
<dd><input type="radio" name="Age" value="25-34">Between 25 and 34 years old</dd>
<dd><input type="radio" name="Age" value="35-44">Between 35 and 44 years old</dd>
<dd><input type="radio" name="Age" value="44+">More than 44 years old </dd>
</dl>
<dl>
<dt> 2) How often do you visit my page?</dt>
<dd><input type="radio" name="Visit" value="Daily">Every Day</dd>
<dd><input type="radio" name="Visit" value="Weekly">Every Week</dd>
<dd><input type="radio" name="Visit" value="Monthly">Once per month</dd>
<dd><input type="radio" name="Visit" value="Yearly">Once per year</dd>
</dl>