<!DOCTYPE HTML>
<html lang="es">
<head>
<title>Reportar link roto</title>
<link rel="shortcut icon" href="" type="image/x-icon" />
<meta charset="UTF-8" />
<style>body{font:1em Lucida Grande,'Trebuchet MS',verdana,sans-serif;font-size:76%;}#form{border:3px double #C16565;background-color:#FFF;padding:5px;width:440px;margin:auto;float:left;}#form h2{font-size:2em;margin:0 0 0.5em 0;padding:0;}#form .campo{border:1px solid #999;padding:5px;}#form .campo2{border:1px solid #999;padding:5px;}color:2875ad;}#form .error{border:1px solid #F00;padding:0.3em;font-size:1.5em;}#form .com{border:1px solid #999;padding:0.3em;font-size:1.5em;width:18em;height:10em;font:1.5em Lucida Grande,'Trebuchet MS',verdana,sans-serif;}#form .com-error{border:1px solid #F00;padding:0.3em;font-size:1.2em;width:18em;height:10em;font:1.5em Lucida Grande,'Trebuchet MS',verdana,sans-serif;}#form .boton{border:2px solid #999;padding:0.3em;font-size:1.2em;width:130px;}#error{border:1px dashed #F00;background-color:#FFF;padding:5px;}#ok{border:1px dashed #060;background-color:#FFF;padding:5px;}</style>
</head>
<body>
<form action="envia.php" method="post">
<div id="form">
Navegadores Soportados: <img src="http://3.bp.blogspot.com/--kwBZPSyrIU/Ukm31gA6awI/AAAAAAAACRI/vj5M6daRHO8/s16-c/Firefox+Browser+for+Android.jpg"> <img src="http://2.bp.blogspot.com/-jWCs0SfAZ5E/UbH1a6ufJHI/AAAAAAAAByw/rcmDDpyJSX8/s16/Chrome-logo.png">
<h2>Reportar Enlace:</h2>
<div style="border:1px solid #970000;padding:5px;background:#F0D360;">
<b>Enlace:</b>
<br/>
<label>Link:
<input type="text" name="link" value="<?php
function dameURL(){
$url="http://".$_SERVER['HTTP_HOST'].":".$_SERVER['SERVER_PORT'].$_SERVER['REQUEST_URI'];
return $url;
}
echo dameURL();
?>"/>
</label> </div>
<br/>
<br/>
<label>Nombre:
<input type="text" name="nombre" required />
</label>
<label>Email:
<input type="email" name="email" required />
</label><br/>
<p>Te conectas desde...:<br/>
<label><input type="radio" name="opcion" value="PC"/>PC</label>
<label><input type="radio" name="opcion" value="Laptop"/>Laptop</label>
<label><input type="radio" name="opcion" value="Tablet"/>Tablet</label>
<label><input type="radio" name="opcion" value="Movil "/>Movil </label>
<label><input type="radio" name="opcion" value="Movil (Android)"/>Movil (Android)</label></p>
<p>
<label><input type="radio" name="opcion" value="Iphone "/>Iphone </label>
<label><input type="radio" name="opcion" value="Ipad "/>Ipad </label>
<label><input type="radio" name="opcion" value="Smart TV "/>Smart TV </label>
<label><input type="radio" name="opcion" value="PlayStation "/>PlayStation </label>
</p>
<p><label> Indique los errores que presenta la pelicula: <br/>
<textarea style="text-align:justify" cols="50" rows="3" name="reporte"></textarea>
</label></p>
<label><input type="submit" value="Enviar"/></label>
</form>
</body>
</html>
