<?php if(isset($_POST['send'])) {

#      elseif ($_REQUEST[ 'name' ]) == ""
#	echo "Please go back and enter a name.";

   include("dbconnect.php");
   $name = $_REQUEST['name'];
   $gender = $_REQUEST['gender'];
   $dob = $_REQUEST['dob'];
   $telephone = $_REQUEST['telephone'];
   $email = $_REQUEST['email'];
   $comment = $_REQUEST['comment'];
   $ip = $_SERVER['REMOTE_ADDR'];
   $browser = $_SERVER['HTTP_USER_AGENT'];
   $port = $_SERVER['SERVER_PORT'];
   
	echo $name;
	echo $gender;
	echo $dob;
	echo $telephone;
	echo $email;
	echo $comment;
	echo $ip;
	echo $browser;

	$query="INSERT INTO feedback VALUES ('$name', '$gender', '$dob', '$telephone', '$email', '$ip', '$browser', '$port', '$comment')";
	mysql_query($query);
	echo mysql_error();

} else {
    
	echo ('	<center>');
  	echo (' <form action="'.htmlspecialchars($_SERVER['PHP_SELF']).'" method="post">');
	echo ('	<table cellpadding="3px" cellspacing="0px" border="0px">');
	echo ('	<tr><td>Name:</td><td> <input type="Text" name="name" size="25"></td></tr>');
	echo ('	<tr><td>Gender:</td><td><select name="gender"><option value="male">Male</option><option value="female">Female</option></select></td></tr>');
	echo ('	<tr><td>D.O.B:</td><td> <input type="Text" name="dob" size="25"></td></tr>');
	echo ('	<tr><td>Telephone:</td><td> <input type="Text" name="telephone" size="25"></td></tr>');
	echo ('	<tr><td>Email:</td><td> <input type="Text" name="email" size="25"></td></tr>');
	echo ('	<tr><td>Comment:</td><td> <textarea cols="25" rows="5" name="comment"></textarea></td></tr>');
	echo ('	<tr><td><input type="submit" name="send" value="Submit"></td><td><input type="reset" name="reset" value="Reset"></td></tr>');
	echo ('	</table>');
	echo ('	</form>');
	echo ('	</center>');

}

?>