Pop Up Form Help

irishpeck · December 3, 2010

Hi GUys,

I recently just done a website for a client at www.smartinsuranceclaim.ie/newebsite on this website i have a page called "Make A Claim" this page is a pop up form that opens in on top of the page that the customer is on. Can someone please help me edit this pop up form first of all to include drop downs and second of all i want to be able to send this form to my email address.

Heres the code for the Form now this will include dropdowns!!! -

<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml" xml:lang="en">
<head>

<link href="css/all.css" rel="stylesheet" type="text/css" media="all" />
<link href="css/styles/spectrum/spectrum.css" rel="stylesheet" type="text/css" media="all" />
<!-- layout style -->
	<link href="css/reset.css" rel="stylesheet" type="text/css" media="screen" />
	<link href="css/typography.css" rel="stylesheet" type="text/css" media="screen" />
    <link href="css/style.css" rel="stylesheet" type="text/css" media="screen" />	
	<!-- jquery -->
	<script type="text/javascript" src="scripts/jquery-1.2.6.min.js"></script>
	<!-- superfish -->
	<link rel="stylesheet" type="text/css" href="css/superfish.css" media="screen" />
	<script type="text/javascript" src="scripts/hoverIntent.js"></script>
	<script type="text/javascript" src="scripts/superfish.js"></script>
	<!-- jcarousel -->
	<script type="text/javascript" src="scripts/jquery.jcarousel.pack.js"></script>
	<link rel="stylesheet" type="text/css" href="css/jquery.jcarousel.css" />
	<link rel="stylesheet" type="text/css" href="css/skin.css" />
	<!-- initialize slider -->

	<script type="text/javascript">

		jQuery(document).ready(function() {
		    jQuery('#mycarousel').jcarousel({
		        vertical: true,
		        scroll: 1
		    });
		});

	</script>
	<!-- slider -->
	<script type="text/javascript" src="scripts/easySlider1.5.js"></script>
	<!-- initialize contact form -->
	<script type="text/javascript" src="scripts/contact.js"></script>
	<!-- initialize jquery plugins -->
	<script type="text/javascript" src="scripts/init.js"></script>
	<!--[if IE 6]>
	<script src="scripts/dd_belated_png.js"></script>
	<script>
		DD_belatedPNG.fix('#top-items, #logo, #navmenu-container, #content-container-bg, #header-image-container, #prevBtn a, #nextBtn a, .comments, .post, #footer-container, .vertical-menu li, .vertical-menu li a, img, blockquote');
		DD_belatedPNG.fix('.box-top, .box-center, .box-padding, .box-bottom');
		DD_belatedPNG.fix('.box-2-top, .box-2-center, .box-2-padding, .box-2-bottom');
		DD_belatedPNG.fix('.box-3-top, .box-3-center, .box-3-padding, .box-3-bottom');
	</script>
	<![endif]--> 
</head>

<body>
<div style="padding:15px;"><div id="note"></div>
									<div id="fields">
<p>Please fill out the form below and we'll get back to you as soon as possible!</p>
<form action="javascript:alert('success!');">
	<table>
		<tr>
	    	<td class="body" id="Company">
	    	<strong><label for="Company">Company:</label></strong>
	    	</td>
	    
	    	<td>
	    	<input name="Company" type="text" size="50" />
	    	</td>
			</tr>

	    <tr>
	        <td class="body" id="Contact">
	        <strong><label for="Contact">Company Contact:</label></strong>
	        </td>
	        
	        <td>
	        <input name="Contact" type="text" size="50" />
	        </td>
	  	</tr>
	  
	  	<tr>
	        <td class="body" id="Address">
	        <strong><label for="Address">Address:</label></strong>
	        </td>
	        
	        <td>
	        <input name="Address" type="text" size="50" />
	        </td>
	  	</tr>
	  	
	    <tr>
	        <td class="body" id="Phone">
	        <strong><label for="Phone">Phone:</label></strong>
	        </td>
	        
	        <td>
	        <input name="Phone" type="text" size="50" />
	        </td>
	   </tr>
	  	
	    <tr>
	        <td class="body" id="Email">
	        <strong><label for="Email">Email:</label></strong>
	        </td>
	        <td>
	        <input name="Email" type="text" size="50" />
	        </td>
	  	</tr>
	  	
	    <tr>
	        <td class="body" id="Comments">
	        <strong><label for="Comments">Questions/Comments:</label></strong>
	        </td>
	        <td>
	        <textarea name="comments" cols="48" rows="6"></textarea>
	        </td>
	  	</tr>
	    
	  	<tr>
	        <td></td>
	        <td><input type="submit" value="Submit" id="submit" class="form-submit" /></td>
	  	</tr>
	</table>
</form>
</div>
</body>
</html>

This is the php code. Please help me edit this in order to send all the details to my address.

<?php

/*
Credits: Bit Repository
URL: http://www.bitrepository.com/
*/

include 'config.php';

error_reporting (E_ALL ^ E_NOTICE);

$post = (!empty($_POST)) ? true : false;

if($post)
{
include 'functions.php';

$name = stripslashes($_POST['name']);
$email = trim($_POST['email']);
$subject = stripslashes($_POST['subject']);
$message = htmlspecialchars($_POST['message']);


$error = '';

// Check name

if(!$name)
{
$error .= 'Please enter your name.<br />';
}

// Check email

if(!$email)
{
$error .= 'Please enter an e-mail address.<br />';
}

if($email && !ValidateEmail($email))
{
$error .= 'Please enter a valid e-mail address.<br />';
}

// Check message (length)

if(!$message || strlen($message) < 10)
{
$error .= "Please enter your message. It should have at least 10 characters.<br />";
}


if(!$error)
{
$mail = mail(WEBMASTER_EMAIL, $subject, $message,
     "From: ".$email."\r\n"
    ."Reply-To: ".$email."\r\n"
    ."X-Mailer: PHP/" . phpversion());

if($mail)
{
echo 'OK';
}

}
else
{
echo '<div class="notification_error">'.$error.'</div>';
}

}
?>

Someone Please Help!!

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