Ecco:



codice:
		<form name="modulo" id="form_446072" class="appnitro" onSubmit="return controllo();" method="post" action="<?=$_SERVER['PHP_SELF'] ?>">
					<div class="form_description" align"center">
			
<h2>INSERISCI I DATI E INVIA LA RICHIESTA</h2>
			

Se siete una coppia inserire i dati solo di una persona. verrete comunque ricontattati. 
I campi delimitati da un "*" sono obbligatori.</p>
		</div>						
			<ul >
			
					<li id="li_1" >
		<label class="description" for="element_1">NOME* </label>
		<span>
			<input id="nome" name= "nome" class="element text" maxlength="255" size="8" value=""/>
			<label>Nome</label>
		</span>
		<span>
			<input id="cognome" name= "cognome" class="element text" maxlength="255" size="14" value=""/>
			<label>Cognome</label>
		</span> 
		
		<li id="li_2" >
		<label class="description" for="element_2">NATA/O A </label>
		<div>
			<input id="element_2" name="element_2" class="element text medium" type="text" maxlength="255" value=""/> 
		</div> 
				<li id="li_3" >
		<label class="description" for="element_3">IL </label>
		<span>
			<input id="element_3_2" name="element_3_2" class="element text" size="2" maxlength="2" value="" type="text"> /
			<label for="element_3_2">GG</label>
		</span>
		<span>
			<input id="element_3_1" name="element_3_1" class="element text" size="2" maxlength="2" value="" type="text"> /
			<label for="element_3_1">M</label>
		</span>
		<span>
	 		<input id="element_3_3" name="element_3_3" class="element text" size="4" maxlength="4" value="" type="text">
			<label for="element_3_3">ANNO</label>
		</span>
	
		<span id="calendar_3">
				
		</span>
		<script type="text/javascript">
			Calendar.setup({
			inputField	 : "element_3_3",
			baseField    : "element_3",
			displayArea  : "calendar_3",
			button		 : "cal_img_3",
			ifFormat	 : "%e %B, %Y",
			onSelect	 : selectDate
			});
		</script>
		 
		
		<li id="li_4" >
		<label class="description" for="element_4">INDIRIZZO </label>
		
		<div>
			<input id="element_4_1" name="element_4_1" class="element text large" value="" type="text">
			<label for="element_4_1">Via, Piazza, etc..</label>
		</div>
	
		<div>
			<input id="element_4_2" name="element_4_2" class="element text large" value="" type="text">
			<label for="element_4_2">Via, Piazza, etc..</label>
		</div>
	
		<div class="left">
			<input id="element_4_3" name="element_4_3" class="element text medium" value="" type="text">
			<label for="element_4_3">Cittā</label>
		</div>
	
		<div class="right">
			<input id="element_4_4" name="element_4_4" class="element text medium" value="" type="text">
			<label for="element_4_4">Provincia</label>
		</div>
	
		<div class="left">
			<input id="element_4_5" name="element_4_5" class="element text medium" maxlength="15" value="" type="text">
			<label for="element_4_5">CAP</label>
		</div>
	
		<div class="right">
			<select class="element select medium" id="element_4_6" name="element_4_6"> 
			<option value="" selected="selected"></option>
<option value="Vanuatu" >Vanuatu</option>
<option value="Vatican City" >Vatican City</option>
<option value="Venezuela" >Venezuela</option>
<option value="Vietnam" >Vietnam</option>
<option value="Yemen" >Yemen</option>
<option value="Zambia" >Zambia</option>
<option value="Zimbabwe" >Zimbabwe</option>
	
			</select>
		<label for="element_4_6">Paese</label>
	</div> 
		
		<li id="li_5" >
		
		<label class="description" for="element_5">TELEFONO* </label>
		<span>
			<input id="telefono" name="telefono" class="element text" size="3" maxlength="3" value="" type="text"> -
			<label for="element_5_1">123</label>
		</span>
		<span>
			<input id="telefono" name="telefono" class="element text" size="3" maxlength="3" value="" type="text"> -
			<label for="element_5_2">123</label>
		</span>
			<span>
	 		<input id="telefono" name="telefono" class="element text" size="4" maxlength="4" value="" type="text">
			<label for="element_5_3">1234</label>
		</span>
		 
		
		<li id="li_6" >
		<label class="description" for="element_6">Email </label>
		<div>
			<input id="element_6" name="element_6" class="element text medium" type="text" maxlength="255" value=""/> 
		</div> 
				<li id="li_9" >

		<label class="description" for="element_9">COME CLASSIFICHERESTI IL TUO BALLO ATTUALE?* </label>
		<div>
		<select class="element select medium" id="element_9" name="element_9"> 
<option value="1" >Pricipiante</option>
<option value="2" >Intermedio</option>
<option value="3" >Avanzato</option>

		</select>
		</div> 
				<li id="li_8" >

		<label class="description" for="element_8">CONTRASSEGNA I BALLI CHE VORRESTI IMPARARE </label>
		<span>
			<input id="element_8_1" name="element_8" class="element radio" type="radio" value="1" />
<label class="choice" for="element_8_1">V. Lento</label>
<input id="element_8_2" name="element_8_1" class="element radio" type="radio" value="2" />
<label class="choice" for="element_8_2">Tango</label>
<input id="element_8_3" name="element_8_2" class="element radio" type="radio" value="3" />
<label class="choice" for="element_8_3">Foxtrot</label>
<input id="element_8_4" name="element_8_3" class="element radio" type="radio" value="4" />
<label class="choice" for="element_8_4">V. Viennese</label>
<input id="element_8_5" name="element_8_4" class="element radio" type="radio" value="5" />
<label class="choice" for="element_8_5">Paso Doble</label>
<input id="element_8_6" name="element_8_5" class="element radio" type="radio" value="6" />
<label class="choice" for="element_8_6">Rumba</label>
<input id="element_8_7" name="element_8_6" class="element radio" type="radio" value="7" />
<label class="choice" for="element_8_7">Cha Cha</label>
<input id="element_8_8" name="element_8_7" class="element radio" type="radio" value="8" />
<label class="choice" for="element_8_8">Swing</label>
<input id="element_8_9" name="element_8_8" class="element radio" type="radio" value="9" />
<label class="choice" for="element_8_9">Samba</label>
<input id="element_8_10" name="element_8_9" class="element radio" type="radio" value="10" />
<label class="choice" for="element_8_10">Salsa</label>
<input id="element_8_11" name="element_8_10" class="element radio" type="radio" value="11" />
<label class="choice" for="element_8_11">Bachata</label>
<input id="element_8_12" name="element_8_11" class="element radio" type="radio" value="12" />
<label class="choice" for="element_8_12">Mambo</label>
<input id="element_8_13" name="element_8_12" class="element radio" type="radio" value="13" />
<label class="choice" for="element_8_13">Merengue</label>
<input id="element_8_14" name="element_8_13" class="element radio" type="radio" value="14" />
<label class="choice" for="element_8_14">Mazurka</label>
<input id="element_8_15" name="element_8_14" class="element radio" type="radio" value="15" />
<label class="choice" for="element_8_15">Polka</label>
<input id="element_8_16" name="element_8_15" class="element radio" type="radio" value="16" />
<label class="choice" for="element_8_16">Country</label>
<input id="element_8_17" name="element_8_16" class="element radio" type="radio" value="17" />
<label class="choice" for="element_8_17">C/W Swing</label>
<input id="element_8_18" name="element_8_17" class="element radio" type="radio" value="18" />
<label class="choice" for="element_8_18">Tango Argentino</label>
<input id="element_8_19" name="element_8_18" class="element radio" type="radio" value="19" />
<label class="choice" for="element_8_19">Milonga</label>
<input id="element_8_20" name="element_8_19" class="element radio" type="radio" value="20" />
<label class="choice" for="element_8_20">Tango Vals</label>
<input id="element_8_21" name="element_8_20" class="element radio" type="radio" value="21" />
<label class="choice" for="element_8_21">Bolero</label>

		</span> 
				<li id="li_7" >
		<label class="description" for="element_7">Altro </label>
		<div>
			<input id="element_7" name="element_7" class="element text medium" type="text" maxlength="255" value=""/> 
		</div> 
				<li id="li_10" >

		<label class="description" for="element_10">COME HAI CONOSCIUTO IL SITO?* </label>
		<span>
			<input id="sito" name="sito" class="element radio" type="radio" value="1" />
<label class="choice" for="element_10_1">Internet</label>
<input id="element_10_2" name="element_10" class="element radio" type="radio" value="2" />
<label class="choice" for="element_10_2">Volantini</label>
<input id="element_10_3" name="element_10" class="element radio" type="radio" value="3" />
<label class="choice" for="element_10_3">Giornali</label>
<input id="element_10_4" name="element_10" class="element radio" type="radio" value="4" />
<label class="choice" for="element_10_4">Amici</label>
<input id="element_10_5" name="element_10" class="element radio" type="radio" value="5" />
<label class="choice" for="element_10_5">Altro</label>

		</span> 
				<li id="li_9" >

		<label class="description" for="element_9">IN QUALE SCUOLA DESIDERI BALLARE?* </label>
		<div>
		<select class="element select medium" id="element_9" name="element_9"> 
		
<?php
	$c=mysql_connect ("62.149.150.141", "Sql489362" , "2af6142e");
	mysql_query ("use Sql489362_5", $c);
	$sql="select * from newsletter_categories where id >1 order by name";
	$dati=mysql_query($sql);

	while($riga=mysql_fetch_array($dati))
	{
		echo "<option value=" .  $riga['id'] .">" . $riga['name'] ."</option>";
	}
?>


		</select>
		</div> 
		

		
<div class="form_description"></div>
			

QUESTA PICCOLA INTERVISTA CI AIUTERA' A PERSONALIZZARE IL TUO BALLO. TI PREGHIAMO DI RISPONDERE ALLE DOMANDE SOTTOSTANTI O LASCIARE VUOTO LO SPAZIO.</p>
						
			<ul >
			
					<li id="li_1" >
		<label class="description" for="element_1">DA QUANTO TEMPO VOLEVI IMPARARE A BALLARE? </label>
		<div>
			<textarea id="element_1" name="element_1" class="element textarea medium"></textarea> 
		</div> 
		
		<li id="li_2" >
		<label class="description" for="element_2">COME MAI HAI DECISO PROPRIO ADESSO DI INIZIARE A BALLARE? </label>
		<div>
			<textarea id="element_2" name="element_2" class="element textarea medium"></textarea> 
		</div> 
		
		<li id="li_3" >
		<label class="description" for="element_3">QUALCUNO SA CHE STAI PER BALLARE? COSA NE PENSANO? </label>
		<div>
			<textarea id="element_3" name="element_3" class="element textarea medium"></textarea> 
		</div> 
		
		<li id="li_4" >
		<label class="description" for="element_4">QUANTE VOLTE A SETTIMANA VORRESTI DEDICARE AL TUO BALLO? </label>
		<div>
			<textarea id="element_4" name="element_4" class="element textarea medium"></textarea> 
		</div> 
		
		<li id="li_5" >
		<label class="description" for="element_5">COSA TI ASPETTI DA QUESTA ESPERIENZA? </label>
		<div>
			<textarea id="element_5" name="element_5" class="element textarea medium"></textarea> 
		</div> 
		
		<li id="li_6" >
		<label class="description" for="element_6">SEI IN COPPIA O LO FAI PER TE STESSO/A? </label>
		<div>
			<textarea id="element_6" name="element_6" class="element textarea medium"></textarea> 
		</div> 
		
		
			
					<li class="buttons">
			    <input type="hidden" name="form_id" value="446072" />
			    
				<input id="saveForm" class="button_text" type="submit" VALUE="invia" />
		
			[/list]
		</form>	
	</div>
</html>