galaxy/Forms/mi-series_bad-jellyfish-23.html

<div class="testbox">
        <form action="/">
          <p id="h1">Feedback Form</p>
          <p id="h4">Name</p>
          <input placeholder="Enter your full name" type="text" class="input">
          <p id="h4">Email<span>*</span></p>
          <input placeholder="Enter your email" type="text" class="input">
          <p id="h4">What is your overall impression?<span>*</span></p>
          <table>
            <tbody><tr>
              <th class="first-col"></th>
              <th>Very Satisfied</th>
              <th>Satisfied</th>
              <th>Unsatisfied</th>
              <th>Very Unsatisfied</th>
            </tr>
            <tr>
              <td class="first-col">Professional</td>
              <td><input name="point#2" value="none" type="radio"></td>
              <td><input name="point#2" value="none" type="radio"></td>
              <td><input name="point#2" value="none" type="radio"></td>
              <td><input name="point#2" value="none" type="radio"></td>
            </tr>
          </tbody></table>
          <p id="h4">Feel free to add any other comments or suggestions:</p>
          <textarea rows="5"></textarea>
          <div class="btn-block">
            <button href="/" type="submit">Send Feedback</button>
          </div>
        </form>
      </div>
<style>
/* From Uiverse.io by mi-series - Tags: simple, form, survey form, feedback, survey */
form, p {
  padding: 0;
  margin: 0;
  outline: none;
  font-family: Roboto, Arial, sans-serif;
  font-size: 14px;
  color: #000;
  line-height: 13px;
  border-radius: 10px;
}

#h1 {
  font-size: 24px;
  font-weight: 400;
  text-align: center;
}

#h4 {
  margin: 20px 0 2px;
  color: #000;
}

.testbox {
  display: flex;
  justify-content: center;
  align-items: center;
  height: inherit;
  padding: 80px;
}

form {
  width: 100%;
  padding: 20px;
  background: #EBEBE1;
  box-shadow: 0 2px 5px #ccc;
}

.input {
  width: calc(100% - 10px);
  padding: 5px;
  border: 1px solid #000;
  border-radius: 3px;
  vertical-align: middle;
  background-color: #F7F7F7;
}

.input:hover, textarea:hover {
  outline: none;
  border: 1px solid #000;
}

.first-name {
  margin-bottom: 5px;
}

th, td {
  width: 21%;
  padding: 15px 0;
  border-bottom: 1px solid #ccc;
  text-align: center;
  vertical-align: set;
  line-height: 18px;
  font-weight: 400;
  word-break: break-all;
}

.first-col {
  width: 16%;
  text-align: left;
}

table {
  width: 100%;
}

textarea {
  width: calc(100% - 6px);
  background: #F7F7F7;
  border-radius: 5px;
}

.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: #F3D153;
  font-size: 16px;
  color: #000;
  cursor: pointer;
}

button:hover {
  opacity: .9;
}

@media (min-width: 568px) {
  th, td {
    word-break: keep-all;
  }
}
</style>