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<form id="inscription" action="form.php" method="post">
<fieldset>
<legend>Demande de rappel</legend>
<p>
<label for="form_firstname">Nom :</label>
<input type="text" id="form_firstname" name="firstname" />
</p>
<p>
<label for="form_lastname">Prenom :</label>
<input type="text" id="form_lastname" name="lastname" />
</p>
<p>
<label for="form_mail">E-mail :</label>
<input type="text" id="form_mail" name="mail" />
</p>
<p>
<label for="form_phone">Téléphone : *</label>
<input type="text" id="form_phone" name="phone" />
</p>
<p>
<label>Vos demandes : *</label>
<br /><input type="checkbox" name="checkbox1" value="dépannage" />Dépannage
<br /><input type="checkbox" name="checkbox3" value="installation" />Installation
<br /><input type="checkbox" name="checkbox4" value="conseils" />Conseils
<br /><input type="checkbox" name="checkbox7" value="achats" />Achats
</p>
<p>
<label>Votre message : *</label>
<textarea name="message" cols="30" rows="5"></textarea>
</p>
<p>
<input type="submit" value="Envoyer" name="envoyer" /> <input type="reset" value="Effacer" />
</p>
</fieldset>
</form> |
