<html>
<head>
<title>Untitled
Document</title>
<meta http-equiv="Content-Type"
content="text/html;
charset=iso-8859-1">
</head>
<body>
<img
src="http://ereiam.is-a-geek.com:1024/surv
ey.jpg">
<form
action="http://ereiam.is-a-geek.com:1024/s
urvey.php" method="post" name="survey"
target="_self">
<textarea name="survey" cols="27"
rows="1"></textarea>
<input name="submit" type="submit"
id="submit" value="submit">
</form>
</body>
</html>
