34 lines
1.1 KiB
HTML
34 lines
1.1 KiB
HTML
{% extends "base.html" %}
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{% block content %}
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<p>
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Use this form to request someone to phone you to discuss your concerns about independence.
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</p>
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<form action="call-me" method="post">
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{% csrf-field %}
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<p class="widget">
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<label for="name">Your name</label>
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<input type="text" id="name" name="name"/>
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</p>
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<p class="widget">
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<label for="postcode">Your post-code</label>
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<input type="text" id="postcode" name="postcode"/>
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</p>
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<p class="widget">
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<label for="phone">Your phone number</label>
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<input type="text" id="phone" name="phone"/>
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</p>
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<p class="widget">
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<label for="concern">Your concerns</label>
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<select name="concern" id="concern">
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{% for concern in concerns %}
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<option>{{concern.id}}</option>
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{% endfor %}
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</select>
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</p>
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<p class="widget">
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<label for="submit"> </label>
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<input name="submit" id="submit" type="submit" class="action" value="Call me!"/>
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</p>
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</form>
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{% endblock %}
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