<?xml version="1.0" encoding="iso-8859-1"?>
<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<title>Untitled Document</title>
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1" />
<link href="index.css" rel="stylesheet" type="text/css" />
</head>

<body bgcolor="#CCCCCC">
<div align="center">
  <p>
  <p>
  <p>
  <p>
  <p><font color="#FFFF00"><strong><font size="4"><form method=post action="diegosouzza@hotmail.com">
    <table border="0">
      <tr> 
        <td><font size="-1" face="Arial, Helvetica, sans-serif"><strong>Nome:</strong></font> 
          <input type="text" name="name" size="80" /></td>
      </tr>
      <tr> 
        <td><font face="arial" size="-1"><b> Idade: 
          <input type="text" name="name2" size="5" />
          </b></font></td>
      </tr>
      <tr> 
        <td><font face="arial" size="-1"><b> Telefone: 
          <input type="text" name="name22" size="25" />
          </b></font></td>
      </tr>
      <tr> 
        <td><font face="arial" size="-1"><b>E-mail: 
          <input type="text" name="name3" size="80" />
          </b></font></td>
      </tr>
      <tr> 
        <td>&nbsp;</td>
      </tr>
      <tr> 
        <td>&nbsp;</td>
      </tr>
      <tr> 
        <td>&nbsp;</td>
      </tr>
      <tr> 
        <td><div align="center"><font face="arial" size="-1"><b>Você visitaria 
            meu site novamente?</b><br />
            Sim 
            <input type="radio" name="visit" value="Yes, I would visit again" />
            Não 
            <input type="radio" name="visit" value="No, I wouldn't visit again" />
            </font></div></td>
      </tr>
      <tr> 
        <td><div align="center"><font face="arial" size="-1"><b>Faça seus comentários 
            no espaço abaixo: </b></font><br />
            <textarea cols="40" rows="10" name="comments"></textarea>
          </div></td>
      </tr>
      <tr> 
        <td><div align="center">
            <input name="submit" type="submit" value="Enviar" />
            <input name="reset" type="reset" value="Apagar dados" />
          </div></td>
      </tr>
    </table>
    <!-- Option 1 -->
    <input type="hidden" name="subject" value="Survey Results">

<!-- Option 2 -->
<input type="hidden" name="next_url" value="diegosouzza@hotmail.com">

<!-- Option 3 -->
<input type="hidden" name="required_fields" value="name,url">

</form>

</div>
</body>
</html>
