<!DOCTYPE html>
<html>
<head>
<title>Title of the document</title>
</head>
<body>
<form action="#" method="get">
<input type="text" name="name" placeholder="Enter your name" />
<input type="number" name="Date of birth:" placeholder="Date of birth:" disabled/>
<input type="submit" value="Submit" />
</form>
</body>
</html>