<form name="bise" method="post">
<p>
Site Adı:<input type="text" name="site">
</p>
<p>
Site Adresi:<input type="text" name="adres">
</p>
<p>
Anlık Online:
<select name="online">
<option>0-50<option>
<option>50-100<option>
<option>100-150<option>
</select>
</p>
<p>
Email:<input type="text" name="email">
</p>
<input type="submit" value="yolla">
</form>