Web Support -- Feedback Form
Using the code found in this document, you may set up a feedback form to which you may add or delete fields according to your needs. Be sure to create a confirmation page.

This is a very basic form. If you require a more sohpisticated form, please see our FAQ for information about where you can find scripts on the internet and how to run them on DCANet's servers.

If you do not understand how to use the code in this document please check out the on-line Perl scripting resources on Yahoo:

Development-related consulting, programming and de-bugging from DCANet is billable at $65/hr, 1/2 hour minimum.

-Copy this source code for the button link:


Interested in receiving more information?<br>

<form action="feedback-form.html">
<input type="submit" name="yes" value="Yes, I am!">
</form>

Copy the following source code into an html file called feedback-form.html. Modify the fields to fit your needs. You'll need to:

-Create and specify a confirmation page (replacing <http://www.yourdomain.com/form-submitted.html> below with your page's pathname)

-Replace recipient@yourdomain.com with the email address to which you want the results to go.

You can add or delete fields, buttons and check boxes. Be sure and use the existing numbering convention so fields are displayed in the desired order.


<h2>Your Company</h2>

If you are interested in receiving information about any of our services, 
please fill in the form below.<p>

<hr>
<form method=POST action="http://www.dca.net/cgi-bin/nph-mail.pl">
<input type="hidden" name="resultspage" value="http://www.yourdomain.com/form-submitted.html">
<input type="hidden" name="email-to" value="recipient@yourdomain.com">
<input type="hidden" name="email" value="from-address@yourdomain.com">
<pre>
Your name	<input name="00-name" size=50>
Address Line 1  <input name="01-address1" size=50> 
Address Line 2	<input name="02-address2" size=50>
City		<input name="03-city" size=50>
State		<input name="04-state" size=10>
ZIP		<input name="05-zip" size=10>
Email address	<input name="06-email" size=50>
Day Phone Number	<input name="07-dayphone" size=15>
Evening Phone Number	<input name="08-eveningphone" size=15>
</pre>

Comments/questions:<br>
<textarea rows=5 cols=60 name="comments" ></textarea><p>

<input type="submit" value="Send it in"> Select when you are finished<p>
<input type="reset"  value="Clear fields"> Select to clear all fields<p>