<!DOCTYPE html>
<html>
<head>
<title>Student Complaint Form</title>
<link href="https://fonts.googleapis.com/css?family=Roboto:300,400,500,700" rel="stylesheet">
<link rel="stylesheet" href="https://use.fontawesome.com/releases/v5.5.0/css/all.css" integrity="sha384-B4dIYHKNBt8Bc12p+WXckhzcICo0wtJAoU8YZTY5qE0Id1GSseTk6S+L3BlXeVIU" crossorigin="anonymous">
<style>
html, body {
min-height: 100%;
}
body, div, form, input, select, p {
padding: 0;
margin: 0;
outline: none;
font-family: Roboto, Arial, sans-serif;
font-size: 14px;
color: #666;
line-height: 22px;
}
h1 {
margin: 15px 0;
font-weight: 400;
}
.testbox {
display: flex;
justify-content: center;
align-items: center;
height: inherit;
padding: 3px;
}
form {
width: 100%;
padding: 20px;
background: #fff;
box-shadow: 0 2px 5px #ccc;
}
input, select, textarea {
margin-bottom: 10px;
border: 1px solid #ccc;
border-radius: 3px;
}
input {
width: calc(100% - 10px);
padding: 5px;
}
select {
width: 100%;
padding: 7px 0;
background: transparent;
}
textarea {
width: calc(100% - 6px);
}
.item {
position: relative;
margin: 10px 0;
}
.item:hover p, .item:hover i {
color: #095484;
}
input:hover, select:hover, textarea:hover, .preferred-metod label:hover input {
box-shadow: 0 0 5px 0 #095484;
}
.preferred-metod label {
display: block;
margin: 5px 0;
}
.preferred-metod:hover input {
box-shadow: none;
}
.preferred-metod-item input, .preferred-metod-item span {
width: auto;
vertical-align: middle;
}
.preferred-metod-item input {
margin: 0 5px 0 0;
}
input[type="date"]::-webkit-inner-spin-button {
display: none;
}
.item i, input[type="date"]::-webkit-calendar-picker-indicator {
position: absolute;
font-size: 20px;
color: #a9a9a9;
}
.item i {
right: 1%;
top: 30px;
z-index: 1;
}
[type="date"]::-webkit-calendar-picker-indicator {
right: 0;
z-index: 2;
opacity: 0;
cursor: pointer;
}
.btn-block {
margin-top: 20px;
text-align: center;
}
button {
width: 150px;
padding: 10px;
border: none;
-webkit-border-radius: 5px;
-moz-border-radius: 5px;
border-radius: 5px;
background-color: #095484;
font-size: 16px;
color: #fff;
cursor: pointer;
}
button:hover {
background-color: #0666a3;
}
@media (min-width: 568px) {
.name-item, .city-item {
display: flex;
flex-wrap: wrap;
justify-content: space-between;
}
.name-item input, .city-item input {
width: calc(50% - 20px);
}
.city-item select {
width: calc(50% - 8px);
}
}
</style>
</head>
<body>
<div class="testbox">
<form action="/">
<h1>Student Complaint Form</h1>
<h5>Personal Information</h5>
<div class="item">
<p>Your Full Legal Name (As Enrolled)</p>
<div class="name-item">
<input type="text" name="name" placeholder="First" />
<input type="text" name="name" placeholder="Last" />
</div>
</div>
<div class="item">
<p>Major</p>
<input type="text" name="name"/>
</div>
<div class="item">
<p>Expected Year of Graduation</p>
<input type="text" name="name"/>
</div>
<div class="item">
<p>Address</p>
<input type="text" name="name" placeholder="Street address"/>
<input type="text" name="name" placeholder="Street address line 2"/>
<div class="city-item">
<input type="text" name="name" placeholder="City" />
<input type="text" name="name" placeholder="Region" />
<input type="text" name="name" placeholder="Postal / Zip code" />
<select>
<option value="">Country</option>
<option value="1">Russia</option>
<option value="2">Germany</option>
<option value="3">France</option>
<option value="4">Armenia</option>
<option value="5">USA</option>
</select>
</div>
</div>
<div class="item">
<p>Email</p>
<input type="text" name="name"/>
</div>
<div class="item">
<p>Phone</p>
<input type="text" name="name"/>
</div>
<div class="item preferred-metod">
<p>Preferred method of contact</p>
<div class="preferred-metod-item">
<label><input type="checkbox" name="name"> <span>Email</span></label>
<label><input type="checkbox" name="name"> <span>Phone</span></label>
<label><input type="checkbox" name="name"> <span>U.S. Mail</span></label>
</div>
</div>
<h5>Information about your complaint</h5>
<div class="item">
<p>First date on which the events or issues occurred</p>
<input type="date" name="name" required/>
<i class="fas fa-calendar-alt"></i>
</div>
<div class="item">
<p>Name(s) of the person(s) involved</p>
<textarea rows="5"></textarea>
</div>
<div class="item">
<p>Please describe your complaint in detail. Include the names of persons, locations, and dates involved. If this complaint is against specific person(s), please list their names and titles</p>
<textarea rows="5"></textarea>
</div>
<div class="item">
<p>What attempts have you made to resolve this complaint up to now? Please state who you contacted and what transpired</p>
<textarea rows="5"></textarea>
</div>
<div class="item">
<p>Why do you think the complaint was not able to be resolved in your prior attempts?</p>
<textarea rows="5"></textarea>
</div>
<div class="item">
<p>What resolution would you consider fair? What resolution do you seek?</p>
<textarea rows="5"></textarea>
</div>
<div class="item">
<p>Any other information you want to provide?</p>
<textarea rows="5"></textarea>
</div>
<div class="btn-block">
<button type="submit" href="/">SEND</button>
</div>
</form>
</div>
</body>
</html>