Simple Php/html Form
We require a simple contact form for a website (14 fields)
Title:
Forename:*
Surname:*
House Number:
Postcode:
Contact Telephone Number:*
Date of Birth:*
Year of Accident:*
Accident Type:*
Call me back:* at
Also to include following fields:
Brief Description of Accident & Circumstances: (Large text box)
How did you find us? (Drop down with following options:
• Word of mouth
• Leaflet
• Business card
• Poster
• Web Search
• Forum
• Local News Paper
• TV/ Radio