How well do you know me?

1. How old am I?

27 28 29 30

2. What is Michael's middle name?

william scott david lee

3. What is my biggest fear?

being alone being divorced being poor loosing my son

4. What illness did I have while pregnant?

preclampsia Hyperemesis toxemia gestational diabetes

Your name

E-mail address

HTML Code

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  <div style="width: 100%;">    
  <h1 style="color: #376e93;">How well do you know me? </h1>
         
    <br />        
      <div style="padding: 5px 0;">1.
      <strong>How old am I?</strong>  
    </div>
                <label style="display: block; margin: 3px 0;"><input type="radio" name="correctAnswer[1124]" value="A" /> 27</label>
                  <label style="display: block; margin: 3px 0;"><input type="radio" name="correctAnswer[1124]" value="B" /> 28</label>
                  <label style="display: block; margin: 3px 0;"><input type="radio" name="correctAnswer[1124]" value="C" /> 29</label>
                  <label style="display: block; margin: 3px 0;"><input type="radio" name="correctAnswer[1124]" value="D" /> 30</label>
      <br />        
      <div style="padding: 5px 0;">2.
      <strong>What is Michael&#039;s middle name?</strong>  
    </div>
                <label style="display: block; margin: 3px 0;"><input type="radio" name="correctAnswer[1125]" value="A" /> william</label>
                  <label style="display: block; margin: 3px 0;"><input type="radio" name="correctAnswer[1125]" value="B" /> scott</label>
                  <label style="display: block; margin: 3px 0;"><input type="radio" name="correctAnswer[1125]" value="C" /> david</label>
                  <label style="display: block; margin: 3px 0;"><input type="radio" name="correctAnswer[1125]" value="D" /> lee</label>
      <br />        
      <div style="padding: 5px 0;">3.
      <strong>What is my biggest fear?</strong>  
    </div>
                <label style="display: block; margin: 3px 0;"><input type="radio" name="correctAnswer[1126]" value="A" /> being alone</label>
                  <label style="display: block; margin: 3px 0;"><input type="radio" name="correctAnswer[1126]" value="B" /> being divorced</label>
                  <label style="display: block; margin: 3px 0;"><input type="radio" name="correctAnswer[1126]" value="C" /> being poor</label>
                  <label style="display: block; margin: 3px 0;"><input type="radio" name="correctAnswer[1126]" value="D" /> loosing my son</label>
      <br />        
      <div style="padding: 5px 0;">4.
      <strong>What illness did I have while pregnant?</strong>  
    </div>
                <label style="display: block; margin: 3px 0;"><input type="radio" name="correctAnswer[1127]" value="A" /> preclampsia</label>
                  <label style="display: block; margin: 3px 0;"><input type="radio" name="correctAnswer[1127]" value="B" /> Hyperemesis</label>
                  <label style="display: block; margin: 3px 0;"><input type="radio" name="correctAnswer[1127]" value="C" /> toxemia</label>
                  <label style="display: block; margin: 3px 0;"><input type="radio" name="correctAnswer[1127]" value="D" /> gestational diabetes</label>
      <br />     
      <div><label for="userName">Your name</label>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
      <input type="text" name="userName" id="userName" value="" style="width: 300px;" />     
    </div><br />
    <div>
      <label for="userEmail">E-mail address</label>
      <input type="text" name="userEmail" id="userEmail" value="" style="width: 300px;" />     
    </div><br />
    	<input type="submit" name="submit" value="Ready" /> <span style="margin-left: 200px;">powered by: <a href="http://www.flufo.com" target="_blank">flufo.com</a></span>
  </div>
</form>

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