<form action="email.php" method="post">
<!-- DO NOT change ANY of the php sections -->
<?php
$ipi = getenv("REMOTE_ADDR");
$httprefi = getenv ("HTTP_REFERER");
$httpagenti = getenv ("HTTP_USER_AGENT");
?>
<input type="hidden" name="ip" value="<?php echo $ipi ?>" />
<input type="hidden" name="httpref" value="<?php echo $httprefi ?>" />
<input type="hidden" name="httpagent" value="<?php echo $httpagenti ?>" />
<h2 align="center">Feedback Form</h2>
<p>
All input is blah blah ...... </p>
<p>Send Data to: <select name="attn" size="1">
<option value=" MT General Email ">General Email</option>
<option value=" MakeTemplate Owner ">Owner of MakeTemplate</option>
<option value=" Technical Support ">Technical Support</option>
<option value=" PHP Codemaster ">PHP Codemaster</option>
</select>
<br />
Name: <input type="text" name="nameis" size="20" /> Email:<input type="text" name="visitormail" size="20" />


<br/> Overall Rating:<br/> [<input checked="checked" name="rating" type="radio" value="good" /> Good]   [<input name="rating" type="radio" value="bad" /> Bad]   [<input name="rating" type="radio" value="ugly" /> Ugly]
</p>
<p> Request additional features for a feedback tutorial:<br />
<input type="checkbox" name="emailvalidation" value="y" /> Email 'format' Validation - check @<br />
<input type="checkbox" name="fieldvalidation" value="y" /> Required Form Field Validation.<br />
<input type="checkbox" name="htmlcontrol" value="y" /> More intergratd HTML (in form).<br />
<input type="checkbox" name="phpform" value="y" /> Improved PHP form script generator.<br />
<input type="checkbox" name="htmlform" value="y" /> A complete HTML form generator. <br />
</p>
<br />
<h3 align="center">General Comments</h3>
<p align="center">
<textarea name="feedback" rows="6" cols="30">Notes n comments here</textarea>
</p>
<hr />
<p align="center">
<input type="submit" value="Submit Feedback" />
</p>
</form>

<h3 align="center">Thanks for your Feedback </h3>
<!-- VIP: change YourEmail to your real email -->
<?php

if((!$visitormail == "") && (!strstr($visitormail,"@") || !strstr($visitormail,".")))
{
echo "<h2>Use Back - Enter valid e-mail</h2>\n";
$tellem = "<h2>Feedback was NOT submitted</h2>\n";
}

if(empty($nameis) || empty($feedback) || empty($visitormail)) {
echo "<h2>Use Back - fill in all fields</h2>\n";
}

echo $tellem;

if ($emailvalidation == "y") {
$req1 = "Email format Validation \n" ;
}

if ($fieldvalidation == "y") {
$req2 = "Required Form Field Validation \n";
}
if ($htmlcontrol == "y") {
$req3 = "More intergratd HTML (in form) \n";
}
if ($phpform == "y") {
$req4 = "Improved PHP form script generator \n";
}
if ($htmlform == "y") {
$req5 = "A complete HTML form generator \n";
}
$req = $req1 . $req2 . $req3 . $req4 . $req5;

$todayis = date("l, F j, Y, g:i a") ;

$attn = $attn;
$subject = $attn;

$feedback = stripcslashes($feedback);

$message = " $todayis [EST] \n
Attention: $attn (Rating: $rating) \n
From: $nameis ($visitormail)\n
Requested:
$req \n
Feedback: $feedback \n
Additional Info : IP = $ip \n
Browser = $httpagent \n
Referral = $httpref
";

$from = "From: $visitormail\r\n";

mail("YourEmail@website.com", $subject, $message, $from);


$screenout = str_replace("\n", "<br/>", $message);
?>


<p align="center">

<?php echo $screenout ?>

</p>