dinbestehjelper.no/application/views/pages/includes/water-channel-form.php

<div class="bookingContainer">
    <div class="bookingTitle" style="color:#19AFCA">Grunnleggende opplysninger</div>
    <form method="post" action="<?php echo base_url();?>booking-process">
        <div class="formRow">
            <label class="formTitle">Navn</label>
            <div class="inputSelectorContainer">
                <input type="text" class="formInputBox" name="name" value="" required>
            </div>
        </div>
        <div class="formRow">
            <label class="formTitle">Adresse</label>
            <div class="inputSelectorContainer">
                <input type="text" class="formInputBox" name="address" value="" required>
            </div>
        </div>
        <div class="formRow">
            <label class="formTitle">E-postadresse</label>
            <div class="inputSelectorContainer">
                <input type="text" class="formInputBox" name="email" value="" required>
            </div>
        </div>
        <div class="formRow">
            <label class="formTitle">Telefonnummer</label>
            <div class="inputSelectorContainer">
                <input type="text" class="formInputBox" name="phonenumber" value="" required>
            </div>
        </div>
        <div class="formRow">
            <label class="formTitle">Bygningstype</label>
            <div class="inputSelectorContainer">
                <input type="radio" class="" name="type_of_building" value="Family house" required><label class="formTitle">Enebolig</label>
            </div>
            <div class="inputSelectorContainer">
                <input type="radio" class="" name="type_of_building" value="Terraced house" required><label class="formTitle">Rekkehus</label>
            </div>
            <div class="inputSelectorContainer">
                <input type="radio" class="" name="type_of_building" value="Housing association" required><label class="formTitle">Borettslag/Sameie</label>
            </div>
        </div>
        <div class="formRow">
            <label class="formTitle">Byggeår</label>
            <div class="inputSelectorContainer">
                <input type="text" class="" name="year_of_construction" value="" required>
            </div>
        </div>
        <div class="formRow">
            <label class="formTitle">Er boligen bebodd under byggearbeidene?</label>
            <div class="inputSelectorContainer">
                <input type="radio" class="" name="home_inhabited" value="" required><label class="formTitle">Ja</label>
            </div>
            <div class="inputSelectorContainer">
                <input type="radio" class="" name="home_inhabited" value="" required><label class="formTitle">Nei</label>
            </div>
        </div>

        <div class="formTitle">Hjelp oss med å finne ut hvilke tjenester du ønsker å benytte deg av:</div>

        <div class="formRow">
            <div class="inputSelectorContainer">
                <label class="formTitle">Rivning av gammelt system (komplett til vannmåler)</label>
                <input type="hidden" name="demolition_of_old_system" value="0">
                <input type="checkbox" class="" name="demolition_of_old_system" value="1">
            </div>
            <div class="inputSelectorContainer">
                <label class="formTitle">Installasjon av nytt system (fra måler)</label>
                <input type="hidden" name="installation_of_new_system" value="0">
                <input type="checkbox" class="" name="installation_of_new_system" value="1">
            </div>
            <div class="inputSelectorContainer">
                <label class="formTitle">Installasjon av vann og avløp i kjøkken</label>
                <input type="hidden" name="installation_of_water_in_kitchen" value="0">
                <input type="checkbox" class="" name="installation_of_water_in_kitchen" value="1">
            </div>
            <div class="inputSelectorContainer">
                <label class="formTitle">Installasjon av vann og avløp på bad</label>
                <input type="hidden" name="installation_of_water_in_the_bathroom" value="0">
                <input type="checkbox" class="" name="installation_of_water_in_the_bathroom" value="1">
            </div>
            <div class="inputSelectorContainer">
                <label class="formTitle">Tilkobling av servant, badekar, dusj</label>
                <input type="hidden" name="connection_of_washbasin" value="0">
                <input type="checkbox" class="" name="connection_of_washbasin" value="1">
            </div>
            <div class="inputSelectorContainer">
                <label class="formTitle">Utskifting av toalett, håndvask, nyinstallasjon</label>
                <input type="hidden" name="replacement_of_toilet" value="0">
                <input type="checkbox" class="" name="replacement_of_toilet" value="1">
            </div>
            <div class="inputSelectorContainer">
                <label class="formTitle">Installasjon av tilkobling for husholdningsapparater</label>
                <input type="hidden" name="installation_of_connection_for_household" value="0">
                <input type="checkbox" class="" name="installation_of_connection_for_household" value="1">
            </div>
            <div class="inputSelectorContainer">
                <label class="formTitle">Tilkobling av oppvaskmaskin</label>
                <input type="hidden" name="connecting_a_dishwasher" value="0">
                <input type="checkbox" class="" name="connecting_a_dishwasher" value="1">
            </div>
            <div class="inputSelectorContainer">
                <label class="formTitle">Tilkobling av vaskemaskin</label>
                <input type="hidden" name="connection_of_washing_machine" value="0">
                <input type="checkbox" class="" name="connection_of_washing_machine" value="1">
            </div>
            <div class="inputSelectorContainer">
                <label class="formTitle">Tilkobling av tørketrommel</label>
                <input type="hidden" name="connection_of_dryer" value="0">
                <input type="checkbox" class="" name="connection_of_dryer" value="1">
            </div>
            <div class="inputSelectorContainer">
                <label class="formTitle">Installasjon av hagekran</label>
                <input type="hidden" name="installation_of_a_garden_tap" value="0">
                <input type="checkbox" class="" name="installation_of_a_garden_tap" value="1">
            </div>
            <div class="inputSelectorContainer">
                <label class="formTitle">Installasjon av vannrenseutstyr</label>
                <input type="hidden" name="installation_of_water_purification" value="0">
                <input type="checkbox" class="" name="installation_of_water_purification" value="1">
            </div>
        </div>

        <div class="formRow">
            <label class="formTitle">Utfyllende kommentarer</label>
            <textarea class="formTextarea" name="user_notes"></textarea>
        </div> 

        <div class="formRow">
            <input type="submit" class="submitButton" name="sendFormWaterChannel" value="Utsendelse">
            <a href="<?php echo base_url();?>booking" class="cancelButton" >Ikke ennå</a>
        </div>    
    </form>
</div>