<FORM METHOD=POST ACTION="/cgi-bin/homestead/mail.pl?jeffterk">

<TABLE WIDTH="600" BORDER="0" CELLSPACING="10" CELLPADDING="0">

<TR>
<TD VALIGN="TOP" ALIGN="RIGHT">
<FONT FACE="ARIAL, HELVETICA" SIZE="-1">
<B>Your first name:</B></FONT><BR>
<INPUT TYPE="text" NAME="field" SIZE="25">
</TD>
<TD VALIGN="TOP" ALIGN="LEFT">
<FONT FACE="ARIAL, HELVETICA" SIZE="-1">
<B>Your URL:</B></FONT><BR>
<INPUT TYPE="text" NAME="field" SIZE="25">
</TD>
</TR>

<TR>
<TD>�</TD>
<TD>�</TD>
</TR>

<TR>
<TD VALIGN="TOP" ALIGN="RIGHT">
<FONT FACE="ARIAL, HELVETICA" SIZE="-1">
<B>Would you visit my web site again?</B><BR>
Yes<INPUT TYPE="radio" NAME="visit" VALUE="Yes, I would visit again">
No<INPUT TYPE="radio" NAME="visit" VALUE="No, I wouldn't visit again">
</TD>
<TD VALIGN="TOP" ALIGN="LEFT">
<FONT FACE="ARIAL, HELVETICA"B SIZE="-1">
<B>How did you hear about my site?</B><BR>
<INPUT TYPE="radio" NAME="hear about" VALUE="Yahoo! GeoCities search">Yahoo! GeoCities search<BR>
<INPUT TYPE="radio" NAME="hear about" VALUE="Yahoo! GeoCities Neighborhoods">Yahoo! GeoCities Neighborhoods<BR>
<INPUT TYPE="radio" NAME="hear about" VALUE="A popular search engine">A popular search engine<BR>
<INPUT TYPE="radio" NAME="hear about" VALUE="Link from another site">Link from another site<BR>
<INPUT TYPE="radio" NAME="hear about" VALUE="From a friend">From a friend
</TD>
</TR>

<TR>
<TD>�</TD>
<TD>�</TD>
</TR>

<TR>
<TD COLSPAN="2" VALIGN="TOP" ALIGN="CENTER">
<FONT FACE="ARIAL, HELVETICA" SIZE="-1">
<B>If you have any comments or suggestions<BR>
for my site please add them below:
</B></FONT><BR>
<TEXTAREA NAME="comments" COLS=40 ROWS=10></TEXTAREA>
<P>

<INPUT TYPE="submit" VALUE="Send">
<INPUT TYPE="reset" VALUE="Clear the form">
</TD>
<TD>�</TD>
</TR>
</TABLE>

<INPUT TYPE="hidden" NAME="subject" VALUE="Survey Results">

<INPUT TYPE="hidden" NAME="next-url" VALUE="/jeffterk/index.html">
</FORM>
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