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Create covidform.html #1041

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117 changes: 117 additions & 0 deletions html-programs/covidform.html
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<!DOCTYPE html>
<html>
<head>
<title>COVID-19 Survey</title>
<link rel="stylesheet" href="styles.css">
</head>
<script src="script.js"></script>
<body>
<center><H1>COVID-19</H1>
<form name="myform">
<table>
<tr>
<td>
<p><H4><b>Full Name:</b></H4><input type = "text" id="Name" name = "name" maxlength="25" placeholder="Name"value="" ><br>
</td>
</tr>
<tr>
<td>
<p><H4><b>Age:</b></H4><input type = "number" id="Age" placeholder="Age"name = "age" maxlength="3" value=""><br>
</td>
</tr>
<tr>
<td>
<p><H4><b>Gender:</b></H4>
<input type="radio" id="Gender" value="male" name="Gender" checked>
<label for="Gender">Male</label>
<input type="radio" id="Gender" value="female" name="Gender">
<label for="Gender">Female</label>
<input type="radio" id="Gender" value="other" name="Gender">
<label for="Gender">Other</label>
</td>
</tr>
<tr>
<td>
<p><H4><b>Symptoms You Have:</b></H4>
<input type="checkbox" id="Symptoms" value="Fever" name="Symptoms">
<label for="Symptoms"> Fever</label><br>
<input type="checkbox" id="Symptoms" value="throat pain" name="Symptoms">
<label for="Symptoms"> Throat Pain</label><br>
<input type="checkbox" id="Symptoms" value="breathing issue" name="Symptoms">
<label for="Symptoms"> Breathing Issue</label><br>
<input type="checkbox" id="Symptoms" value="tiredness" name="Symptoms">
<label for="Symptoms"> Tiredness</label><br>
<input type="checkbox" id="Symptoms" value="body pain" name="Symptoms">
<label for="Symptoms"> Body Pain</label><br>
</td>
</tr>
<tr>
<td>
<p><b>Address:</b><textarea rows="2" cols="50" name="Address" value="Address"></textarea>
</td>
</tr>
<tr>
<td>
<nobr><label><b>Pincode:</b></label>
<input type="number" name="Pincode" placeholder="Pincode"value="" maxlength="6"><br>
</td>
</tr>
<tr>
<td>
<p><label for="district"><h4><b>Choose your District</b></h4></label><select name="district">
<option value="Thiruvananthapuram">Thiruvananthapuram</option>
<option value="Kollam">Kollam</option>
<option value="Pathanamthitta">Pathanamthitta</option>
<option value="Alappuzha">Alappuzha</option>
<option value="Kottayam">Kottayam</option>
<option value="Idukki">Idukki</option>
<option value="Ernakulam">Ernakulam</option>
<option value="Thrissur">Thrissur</option>
<option value="Palakkad">Palakkad</option>
<option value="Malappuram">Malappuram</option>
<option value="Kozhikode">Kozhikode</option>
<option value="Wayanad">Wayanad</option>
<option value="Kannur">Kannur</option>
<option value="Kasaragod">Kasaragod</option>
</select><br><br>
</td>
</table>
<input type="submit" name="submit" onclick="check(); return false" >
</form>

</center>
<!--The details you have entered-->
<center>
<table>
<tr><td>
<p id="d1"></p>
<p id="f1"></p>
</td></tr>
<tr><td>
<p id="d2"></p>
<p id="f2"></p>
</td></tr>
<tr><td>
<p id="d3"></p>
<p id="f3"></p>
</td></tr>
<tr><td>
<p id="d4"></p>
<p id="f4"></p>
</td></tr>
<tr><td>
<p id="d5"></p>
<p id="f5"></p>
</td></tr>
<tr><td>
<p id="d6"></p>
<p id="f6"></p>
</td></tr>
<tr><td>
<p id="d7"></p>
<p id="f7"></p>
</td></tr>
</table>
</center>
</body>
</html>