<?php 
include('header.php');
?>
<html>
<head>
<style>
body {
    background-color:#008B8B;
}

</style>
<body >





<br><br>

<form class="form-horizontal" style="margin-left:360px;" method="POST" action="contact_query.php">
<h2>
 FeedBack Form
</h2>
	<p class="full_name">
	<label for="full_name" style="font-size:18px; font-family:georgia; margin-top:10px;">Your Name</label>
		<input type="text" name="full_name" id="full_name" placeholder="Enter your full name . . . ." autofocus="autofocus" required/>
		
	</p>
		
	<p class="email">
	<label for="email" style="font-size:18px; font-family:georgia margin-top:10px;">Your Email Address</label>
		<input type="email" name="email" id="email" placeholder="Enter your email . . . ." required/>
		
	</p>	
	<p class="mobile">
	<label for="mobile" style="font-size:18px; font-family:georgia margin-top:10px;">Your Mobile Number</label>
		<input type="mobile" name="mobile" id="mobile" placeholder="Enter your Number . . . ." required/>
		
	</p>	
	<p class="tech">
	<label for="tech" style="font-size:18px; font-family:georgia margin-top:10px;">Technology</label> <select name="tech"><br>
    
  <option value="Android">Android </option>
  <option value="Embdded">Embedded</option>
  <option value="Solar">Solar</option>
  <option value="Astrisk">Astrisk</option>

</select>
</p>
<p class="rating">
	<label for="rating" style="font-size:18px; font-family:georgia margin-top:10px;"> <h3>Rate the Questions </h3></label> 
  
</select>
</p>
<p class="q1">
	<label for="q1" style="font-size:18px; font-family:georgia margin-top:10px;"> 
I achieved my goals during the internship by learning ? </label> <select name="q1" ><br>
  <option  value="5">Excellent</option>
  <option  value="4">Very Good</option>
  <option  value="3">Good</option>
  <option  value="2">Average</option>
  <option  value="1">Bad</option>

  

</select><br>
</p>
<p class="q2">
	<label for="q2" style="font-size:18px; font-family:georgia margin-top:10px;">Through my duties, I received training in a profession/field related to my studies. </label> <select name="q2"><br>
    
    <option  value="5">Excellent</option>
  <option  value="4">Very Good</option>
  <option  value="3">Good</option>
  <option  value="2">Average</option>
  <option  value="1">Bad</option>

  

</select><br>
</p>
<p class="q3">
	<label for="q3" style="font-size:18px; font-family:georgia margin-top:10px;">I experienced some of the realities of working in the profession/field.  </label> <select name="q2"><br>
    
    <option  value="5">Excellent</option>
  <option  value="4">Very Good</option>
  <option  value="3">Good</option>
  <option  value="2">Average</option>
  <option  value="1">Bad</option>

  

</select><br>
</p><p class="q4">
	<label for="q4" style="font-size:18px; font-family:georgia margin-top:10px;">I successfully completed my assigned responsibilities and duties. </label> <select name="q4"><br>
    
    <option  value="5">Excellent</option>
  <option  value="4">Very Good</option>
  <option  value="3">Good</option>
  <option  value="2">Average</option>
  <option  value="1">Bad</option>

  

</select><br>
</p>
</select><br>
</p>
	<p class="message">
	<label for="message" style="font-size:18px; font-family:georgia margin-top:10px;">Your Feedback</label>
		<textarea name="message" placeholder="Enter your feedback . . . ." required></textarea>
		
	</p>
	
<div class="control-group" style="float:left; margin-left:-185px;">
	<div class="controls">
	
	<img src="generatecaptcha.php?rand=<?php echo rand(); ?>" name="captcha_img" id='image_captcha' > 
	<a href='javascript: refreshing_Captcha();'><i class="icon-refresh icon-large"></i></a> 
	<script language='JavaScript' type='text/javascript'>
		function refreshing_Captcha()
		{
			var img = document.images['image_captcha'];
			img.src = img.src.substring(0,img.src.lastIndexOf("?"))+"?rand="+Math.random()*1000;
		}
	</script>
	</div>
</div>

<br />
<br />
<br />

<div class="control-group" style="margin-left:-181px;">
	<div class="controls">
		<input id="code" name="code_confirmation" type="text" placeholder="Enter the code above . . . ." required></td>
	</div>
</div>
<div class="control-group" style="margin-left:-181px;">
	<div class="controls">
		<button type="submit" name="send_message" class="btn btn-success"><i class="icon-ok icon-large"></i> Submit</button>
	</div>
</div>

</form>

</body>
</head>
</html>