<?php
if(isset($_POST['send']))
{
 if($_POST['name']=="" || $_POST['gender']=="" || $_POST['dob']=="" || $_POST['email']=="" || $_POST['telephone']=="" || $_POST['comment']=="")
 {
  echo 'Please make sure you entered something in every field. 
 }
 else
 {
  include("dbconnect.php");
  echo $_POST['name'];
  echo $_POST['gender'];
  echo $_POST['dob'];
  echo $_POST['telephone'];
  echo $_POST['email'];
  echo $_POST['comment'];
  echo $_SERVER['REMOTE_ADDR'];
  echo $_SERVER['HTTP_USER_AGENT'];
  echo $_SERVER['SERVER_PORT'];

  $query="INSERT INTO feedback VALUES ('$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>';
}

?>