<HTML>
<HEAD>
<TITLE>Feedback Form</TITLE>
</HEAD>


<BODY>

<TABLE WIDTH=80% ALIGN=center><TR><TD>

<fieldset>
<legend><B>
Please fill out this form and submit it.
</B></legend>

<CENTER>
<FORM Name="MyForm" 
ACTION="process_form_name_repetition.php" METHOD="post">

<!--
<B>Name:</B>
<INPUT NAME="Name" SIZE=30>
<P>
-->

<B>Name:</B>
<INPUT NAME="Name[]" SIZE=30>
<P>

<B>Name:</B>
<INPUT NAME="Name[]" SIZE=30>
<P>

<!--
<B>Name:</B>
<INPUT NAME="Name" SIZE=30>
<P>
-->

<B>Country/State</B>
<INPUT NAME="Country" SIZE=30>
<P>

<B>Age:</B>
<SELECT NAME="Age">
<OPTION>18 - 25
<OPTION>26 - 30
<OPTION>31 - 35
<OPTION>36 - 40
<OPTION>41 - 50
<OPTION> > 50
</SELECT>
<P>

<B>Email:</B>
<INPUT NAME="Email" SIZE=30>
<P>

<B>College Student/Graduate?</B>
<INPUT NAME="College" TYPE="radio" VALUE="Yes">
<B>Yes</B>
<INPUT NAME="College" TYPE="radio" VALUE="No">
<B>No</B>
<P>

<B> 
Iyad's Website is</B>

<SELECT NAME="Rate">
<OPTION>Bad
<OPTION>Good
<OPTION>Excellent
</SELECT>

<P>
<B>Comments:</B>
<TEXTAREA NAME="Comments" ROWS=8 COLS=30 WRAP="virtual">
</TEXTAREA>

<CENTER><INPUT TYPE="submit" VALUE="SUBMIT"></CENTER> 
<INPUT TYPE="reset" VALUE="CLEAR">


</FORM></CENTER>
</fieldset>
</TD></TR></TABLE>

</BODY>
</HTML>


