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Mini Shell

Mini Shell

Direktori : /home/vacivi36/vacinagripe.vacivitta.com.br/pages/
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Current File : /home/vacivi36/vacinagripe.vacivitta.com.br/pages/contact.php

<div class="uk-container">
    <div class="titleBlock">
        <h2 class="uk-text-uppercase uk-text-center uk-margin-remove">preencha o formulário e garanta sua dose</h2>
    </div>

    <div class="formBlock">
        <form class="formMailer" action="https://script.google.com/macros/s/AKfycbzahjAQ2TGsLkaP1HfbuBBTTODIU7nJ2u_elOtLzIomZsDer7NociT9C78Z1uUa018xzQ/exec" method="POST">
            <div class="form-elements uk-grid-small" uk-grid>
                <div class="uk-width-1-2@s">
                    <label class="uk-form-label" for="inputNomeFooter">Nome</label>
                    <input class="uk-input" type="text" name="Nome" id="inputNomeFooter" required>
                </div>
                <div class="uk-width-1-2@s">
                    <label class="uk-form-label" for="inputEmpresaFooter">Empresa</label>
                    <input class="uk-input" type="text" name="Empresa" id="inputEmpresaFooter" required>
                </div>
                <div class="uk-width-1-2@s">
                    <label class="uk-form-label" for="inputCelularFooter">Celular</label>
                    <input class="uk-input" type="text" name="Celular" id="inputCelularFooter" required>
                </div>
                <div class="uk-width-1-2@s">
                    <label class="uk-form-label" for="inputEmailFooter">E-mail</label>
                    <input class="uk-input" type="text" name="Email" id="inputEmailFooter" required>
                </div>
                <div class="uk-width-1-2@s">
                    <label class="uk-form-label" for="inputCidadeFooter">Cidade/Estado</label>
                    <input class="uk-input" type="text" name="Cidade/Estado" id="inputCidadeFooter" required>
                </div>
                <fieldset class="pure-group honeypot-field">
                    <label for="honeypot">To help avoid spam, utilize a Honeypot technique with a hidden text field; must be empty to submit the form! Otherwise, we assume the user is a spam bot.</label>
                    <input id="honeypot" type="text" name="honeypot" value="" />
                </fieldset>
                <div class="uk-width-1-2@s">
                    <label class="uk-form-label" for="inputDosesFooter">Número de Doses</label>
                    <input class="uk-input" type="text" name="Doses" id="inputDosesFooter" required>
                </div>
                <div class="uk-width-1-1">
                    <label class="uk-form-label"><input class="uk-checkbox" type="checkbox" name="Aceito" id="TermosFooter" value="Aceito" required> Aceito receber as comunicações da Vacivitta</label>
                </div>
                <div class="uk-width-1-1">
                    <button class="uk-button uk-button-default uk-width-1-1" type="submit">QUERO GARANTIR MINHA DOSE</button>
                </div>

                <!-- Customize the Thankyou Message People See when they submit the form: -->
                <div class="thankyou_message" style="display:none;">
                    <h6>Obrigado! Em breve, entraremos em contato</h6>
                </div>
            </div>
        </form>
    </div>
</div>

Zerion Mini Shell 1.0