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LiteSpeed

System:

Linux 4.18.0-553.70.1.lve.el8.x86_64

PHP Version:

8.1.33

User:

u998488001

Directory:

/home/u998488001/domains/shrital.com/public_html

Free Space:

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✏️ Editing: bidaji-feedback-form.php

<?php $pg_nm="Feedback Form"?>
	<?php $title="Feedback Form"; ?>
	<?php $desc="Feedback Form Can We Contact You If More Information Is Needed"; ?>
	<?php $keywords="Shri TaL Mukhvas, Healthy Habit, Shri TaL Ajwain Mix, Shri TaL Suva Mix, Shri TaL Plain, Bidaji, Harvis Food, Feedback Form, name, address, email, Mouth Fresher"; ?>
	<?php include 'include/header.php'?>
	<?php include 'include/menu.php'?>
	<?php include 'include/contacts-breadcrumb.php';?>
	<script type="text/javascript">
			window.onload();
			document.getElementById("button1").disabled = true;
			function enableBtn(){
				document.getElementById("button1").disabled = false;
			   }
		</script>
		<script src="https://www.google.com/recaptcha/api.js"></script>
		
		<div class="container p-160-cont">
			<div class="row">
				<div class="col-md-12">
					<div class="row ">
						<div class="col-md-8">
							<h2 class="section-title2">Feedback Form</h2>
							<div class="line-3-100"></div><br>
						</div>
						<div class="col-md-4">
							<h2 class="section-title2"><a class="button large thin deeporange hover-dark btn-download" href="pdf/feed__back_ form_pdf1.pdf" download="feed__back_ form_pdf1.pdf">Download Form</a></h2>
						</div>
					</div>
					
					<div class="tab-content">
					
						 <form id="login-form" action="php/bidaji-feedback.php" method="POST">
							<div class="row mt-15">
								<div class="col-md-12 mb-15">
								<input type="text" name="name" id="name" class="form-control" placeholder="Name*" required>
								</div>
							</div>
							<div class="row mt-15">
								<div class="col-md-12 mb-15">
									<input type="text" name="contact" id="contact" class="form-control" placeholder="Contact*" required>
								</div>
							</div>
							<div class="row mt-15">
								<div class="col-md-12 mb-15">
									<input type="text" name="email" id="email" class="form-control" placeholder="Email*" required>
								</div>
							</div>
							<div class="row mt-15">
								<div class="col-md-12 mb-15">
									<input type="text" name="city" id="city" class="form-control" placeholder="City*" required>
								</div>
							</div><hr> 
							<div class="row mt-15">
								<h3 class="h-3">How Often You Eat Any Mouth Fresher?</h3>
								<div class="col-md-2 col-xs-6 mb-15">
									<input type="checkbox" name="mouth" id="hourly" value="Hourly" class="form-control radiofrm">
									<label for="hourly" class="radiofrm">Hourly</label>
								</div>
								<div class="col-md-2 col-xs-6 mb-15">
									<input type="checkbox" name="mouth" id="1to3hourly"  value="1 to 3 Hourly" class="form-control radiofrm">
									<label for="1to3hourly" class="radiofrm">1 to 3 Hourly</label>
								</div>
								<div class="col-md-2 col-xs-6 mb-15">
									<input type="checkbox" name="mouth" id="4to5hourly" value="4 to 5 Hourly" class="form-control radiofrm">
									<label for="4to5hourly" class="radiofrm">4 to 5 Hourly</label>
								</div>
								<div class="col-md-2 col-xs-6 mb-15">
									<input type="checkbox" name="mouth" id="6to10hourly" value="6 to 10 Hourly" class="form-control radiofrm">
									<label for="6to10hourly" class="radiofrm">6 to 10 Hourly</label>
								</div>
								<div class="col-md-2 col-xs-6 mb-15">
									<input type="checkbox" name="mouth" id="onlyonceinaday" value="Only Once In A Day" class="form-control radiofrm">
									<label for="onlyonceinaday" class="radiofrm">Only Once In A Day</label>
								</div>
							</div><hr>
							<div class="row mt-15">
								<h3 class="h-3">Please Rate From 1-5 Accordingly <span class="h-span">(1-Poor, 2-Fair, 3-Good, 4-Best, 5-Extreme)</span></h3>
								<div class="col-md-12 mb-15">
									<div class="col-md-2 col-xs-12">
										<label for="Taste" class="radiofrm">Taste</label>
									</div>
									<div class="col-md-2">
										Poor <input type="radio" name="taste"  value="Poor" class="form-control radiofrm">
									</div>
									<div class="col-md-2 ">
										Fair<input type="radio" name="taste" value="Fair" class="form-control radiofrm">
									</div>
									<div class="col-md-2">
										Good<input type="radio" name="taste"  value="Good" class="form-control radiofrm">
									</div>
									<div class="col-md-2">
										Best<input type="radio" name="taste" id="Taste" value="Best" class="form-control radiofrm">
									</div>
									<div class="col-md-2">
										Extreme<input type="radio" name="taste" id="Taste" value="Extreme" class="form-control radiofrm">
									</div>
								</div>
								<div class="col-md-12 mb-15">
									<div class="col-md-2 col-xs-12">
										<label for="Taste" class="radiofrm">Packing</label>
									</div>
									<div class="col-md-2">
										Poor <input type="radio" name="packing" id="Taste" value="Poor" class="form-control radiofrm">
									</div>
									<div class="col-md-2">
										Fair<input type="radio" name="packing" id="Taste" value="Fair" class="form-control radiofrm">
									</div>
									<div class="col-md-2">
										Good<input type="radio" name="packing" id="Taste" value="Good" class="form-control radiofrm">
									</div>
									<div class="col-md-2">
										Best<input type="radio" name="packing" id="Taste" value="Best" class="form-control radiofrm">
									</div>
									<div class="col-md-2">
										Extreme<input type="radio" name="packing" id="Taste" value="Extreme" class="form-control radiofrm">
									</div>
								</div>
								<div class="col-md-12 mb-15">
									
									<div class="col-md-2 col-xs-12">
										<label for="Taste" class="radiofrm">Value For Money</label>
									</div>
									<div class="col-md-2">
										Poor <input type="radio" name="value" id="Taste" value="Poor" class="form-control radiofrm">
									</div>
									<div class="col-md-2">
										Fair<input type="radio" name="value" id="Taste" value="Fair" class="form-control radiofrm">
									</div>
									<div class="col-md-2">
										Good<input type="radio" name="value" id="Taste" value="Good" class="form-control radiofrm">
									</div>
									<div class="col-md-2">
										Best<input type="radio" name="value" id="Taste" value="Best" class="form-control radiofrm">
									</div>
									<div class="col-md-2">
										Extreme<input type="radio" name="value" id="Taste"  value="Extreme" class="form-control radiofrm">
									</div>
								</div>
								<div class="col-md-12 mb-15">
									
									<div class="col-md-2 col-xs-12">
										<label for="Taste" class="radiofrm">Product Appearance</label>
									</div>
									<div class="col-md-2">
										Poor <input type="radio" name="product" id="Taste" value="Poor" class="form-control radiofrm">
									</div>
									<div class="col-md-2">
										Fair<input type="radio" name="product" id="Taste" value="Fair" class="form-control radiofrm">
									</div>
									<div class="col-md-2">
										Good<input type="radio" name="product" id="Taste" value="Good" class="form-control radiofrm">
									</div>
									<div class="col-md-2">
										Best<input type="radio" name="product" id="Taste" value="Best" class="form-control radiofrm">
									</div>
									<div class="col-md-2">
										Extreme<input type="radio" name="product" id="Taste"  value="Extreme" class="form-control radiofrm">
									</div>
								</div>
								<div class="col-md-12 mb-15">
									<div class="col-md-2 col-xs-12">
										<label for="Taste" class="radiofrm">Quality</label>
									</div>
									<div class="col-md-2">
										Poor <input type="radio" name="quality" id="Taste" value="Poor" class="form-control radiofrm">
									</div>
									<div class="col-md-2">
										Fair<input type="radio" name="quality" id="Taste" value="Fair" class="form-control radiofrm">
									</div>
									<div class="col-md-2">
										Good<input type="radio" name="quality" id="Taste" value="Good" class="form-control radiofrm">
									</div>
									<div class="col-md-2">
										Best<input type="radio" name="quality" id="Taste" value="Best" class="form-control radiofrm">
									</div>
									<div class="col-md-2">
										Extreme<input type="radio" name="quality" id="Taste" value="Extreme" class="form-control radiofrm">
									</div>
								</div>
								<div class="col-md-12 mb-15">
									
									<div class="col-md-2 col-xs-12">
										<label for="Taste" class="radiofrm">Freshness Of Product</label>
									</div>
									<div class="col-md-2">
										Poor <input type="radio" name="freshness" id="Taste" value="Poor" class="form-control radiofrm">
									</div>
									<div class="col-md-2">
										Fair<input type="radio" name="freshness" id="Taste" value="Fair" class="form-control radiofrm">
									</div>
									<div class="col-md-2">
										Good<input type="radio" name="freshness" id="Taste" value="Good" class="form-control radiofrm">
									</div>
									<div class="col-md-2">
										Best<input type="radio" name="freshness" id="Taste" value="Best" class="form-control radiofrm">
									</div>
									<div class="col-md-2">
										Extreme<input type="radio" name="freshness" id="Taste" value="Extreme" class="form-control radiofrm">
									</div>
								</div>
							</div><hr>
							<div class="row mt-15">
								<div class="col-md-12 mb-15">
									<textarea type="text" name="like" id="like" class="form-control" placeholder="What You Like The Most About Our Product?"></textarea>
								</div>
							</div>
							<div class="row mt-15">
								<div class="col-md-12 mb-15">
									<textarea type="text" name="like2" id="like2" class="form-control" placeholder="What You Did Not Like About Our Product?"></textarea>
								</div>
							</div>
							<div class="row mt-15">
								<div class="col-md-12 mb-15">
									<textarea type="text" name="manufacture" id="manufacture" class="form-control" placeholder="Would You Like To Suggest Any Other Type Of Mouth Fresher For Us To Manufacture?"></textarea>
								</div>
							</div><hr>
							<div class="row mt-15">
								<h3 class="h-3">Can We Contact You If More Information Is Needed?</h3>
								<div class="col-md-2 col-xs-6 mb-15">
									<input type="checkbox" name="information" id="information"  value="Yes" class="form-control radiofrm">
									<label for="yes" class="radiofrm">Yes</label>
								</div>
								<div class="col-md-2 col-xs-6 mb-15">
									<input type="checkbox" name="information" id="information" value="no" class="form-control radiofrm">
									<label for="no" class="radiofrm">No</label>
								</div>						
							</div><hr>
							<div class="row mt-15">
								<h3 class="h-3">Would You Recommend our Product to Other People?</h3>
								<div class="col-md-2 col-xs-6 mb-15">
									<input type="checkbox" name="recommend" id="recommend"  value="Yes" class="form-control radiofrm">
									<label for="yes" class="radiofrm">Yes</label>
								</div>
								<div class="col-md-2 col-xs-6 mb-15">
									<input type="checkbox" name="recommend" id="recommend" value="No" class="form-control radiofrm">
									<label for="no" class="radiofrm">No</label>
								</div>						
							</div><hr>
							<div class="row mt-15">
								<h3 class="h-3">Is It Ok If We Post Your Valuable Comment About Our Product On Our Website Or Facebook Page ?</h3>
								<div class="col-md-2 col-xs-6 mb-15">
									<input type="checkbox" name="valuable" id="valuable"  value="Yes" class="form-control radiofrm">
									<label for="yes" class="radiofrm">Yes</label>
								</div>
								<div class="col-md-2 col-xs-6 mb-15">
									<input type="checkbox" name="valuable" id="valuable" value="No" class="form-control radiofrm">
									<label for="no" class="radiofrm">No</label>
								</div>					
							</div><hr>
							<div class="row mt-15">
								<div class="col-md-12 mb-15">
									<textarea type="text" name="comment" id="comment" class="form-control" placeholder="Comments/Suggestions"></textarea>
								</div>
							</div>
							<div class="row mb-20">
								<div class="col-sm-5"></div>
								<div class="col-sm-2">
								<div class="g-recaptcha" data-sitekey="6Lf9p2sUAAAAAMmei50lMpfmu1LZz0evWHMSX_zV" data-callback="enableBtn"></div>
								    <br>
								<button type="submit" name="send" id= "button1" disabled="disabled" value="SEND MESSAGE" class="button small button rounded medium gray rounded btn-block text-center">Send</button></div>
								<div class="col-sm-5"></div>
							</div>
						</form>
						
					</div>
				</div>
			</div>
		</div>
		<?php include 'include/footer.php'?>

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