<?php 
require_once(dirname(__FILE__).'/koneksi.php');
require_once(dirname(__FILE__).'/common/header.php');
?>

<br/>
<form class="well form-horizontal" action="cek_comment.php" method="post"  id="contact_form">
<fieldset>
<legend>Berikan kritik dan saran anda pada kolom dibawah ini</legend>
<div class="form-group">
  <label class="col-md-4 control-label">Nama</label>  
  <div class="col-md-4 inputGroupContainer">
  <div class="input-group">
  <span class="input-group-addon"><i class="glyphicon glyphicon-user"></i></span>
  <input  name="name" required placeholder="Isi Nama Anda" class="form-control"  type="text">
    </div>
  </div>
</div>
<div class="form-group">
  <label class="col-md-4 control-label">Hp </label>
    <div class="col-md-4 inputGroupContainer">
    <div class="input-group">
        <span class="input-group-addon"><i class="glyphicon glyphicon-earphone"></i></span>
  <input name="phone" required placeholder="Nomor Handphone" class="form-control" type="text">
    </div>
  </div>
</div>
<div class="form-group">
  <label class="col-md-4 control-label">E-Mail</label>  
    <div class="col-md-4 inputGroupContainer">
    <div class="input-group">
        <span class="input-group-addon"><i class="glyphicon glyphicon-envelope"></i></span>
        <input name="email" required placeholder="E-Mail" class="form-control"  type="text">
    </div>
  </div>
</div>
<div class="form-group col-md-8" style="margin-top: 20px;margin-left: 15px;">
<label for="comment" required >Kritik Dan Saran:</label></div>
<textarea class="form-control" rows="5" id="comment" name="comment" placeholder="Masukkan Ulasan Anda"></textarea><br>
<button type="submit" onclick="window.alert('Terimakasih Telah Memberikan Kritik dan Saran!');" class="btn btn-primary" name="kirim"> Kirim <span class="glyphicon glyphicon-send"></span></button>

  &nbsp;
</fieldset>
</form>
<?php
require_once(dirname(__FILE__).'/common/footer.php');
?>