Sample form:

Name:
Password:
Married     Single
I like this script
Hometown:
("Hometown" doesn't remember what you enter in it)

Age:
0-10 11-20 21-30 31-40 41-50 51-60 61-70 over 70

I use the following browsers: (select all that apply)
Netscape Navigator Microsoft Internet Explorer Other

Other Comments:

Script from Cut and Paste JavaScript.