<!doctype html>
<html>
<head>
<meta charset="utf-8">
<title>American Metric 电子产品调查表</title>
</head>
<body>
<form>
<table border="0">
<tr>
<th align="left">
<font size="5">American Metric 电子产品调查表</font>
</th>
</tr>
<tr>
<td>
请输入您的姓名:<input type="text" />
</td>
</tr>
<tr>
<td>
<span>请输入您的购买日期:</span>
<input type="data" name="usert_data" style="50px;"/>
<span>年</span>
<select>
<option>1</option>
<option>2</option>
<option>3</option>
<option>4</option>
<option>5</option>
<option>6</option>
<option>7</option>
<option>8</option>
<option>9</option>
<option>10</option>
<option>11</option>
<option>12</option>
</select>
<span>月</span>
<select>
<option>1</option>
<option>2</option>
<option>3</option>
<option>4</option>
<option>5</option>
<option>6</option>
<option>7</option>
<option>8</option>
<option>9</option>
<option>10</option>
<option>11</option>
<option>12</option>
<option>13</option>
<option>14</option>
<option>15</option>
<option>16</option>
<option>17</option>
<option>18</option>
<option>19</option>
<option>20</option>
<option>21</option>
<option>22</option>
<option>23</option>
<option>24</option>
<option>25</option>
<option>26</option>
<option>27</option>
<option>28</option>
<option>29</option>
<option>30</option>
<option>31</option>
</select>
<span>日</span>
</td>
</tr>
<tr>
<td>
请输入您的电子邮件地址：<input type="email" name="user_email"/>
</td>
</tr>
<tr>
<td>
您是否查看过我们的在想产品目录：
<input type="radio" name="control1" value="0" checked>是
<input type="radio" name="control1" value="1">否
</td>
</tr>
<tr>
<td>
如果查看过，您对那些产品有兴趣购买？（选择提供的产品）
</td>
</tr>
<tr>
<td>
<input type="checkbox" name="checkbox1" value="0">大屏幕电视机
<input type="checkbox" name="checkbox2" value="1">音频设备
<input type="checkbox" name="checkbox3" value="2">视频设备
<input type="checkbox" name="checkbox4" value="3">相机
</td>
</tr>
<tr>
<td>
在填写订单之前，您还有什么问题、意见或建议？
</td>
</tr>
<tr>
<td>
<textarea name="control3" cols="26" rows="5" placeholder="您的输入："></textarea>
</td>
</tr>
<tr>
<td>
<input type="submit" name="submit1" value="提交">
<input type="reset" name="reset1" value="重置">
</td>
</tr>
</table>
</form>
</body>
</html>