berikut form nya
<html>
<head>
<title>Form Pendaftaran KTP</title>
<script language="JavaScript">
var txt="......Form Pendaftaran KTP .......";
var kecepatan=100;var segarkan=null;function bergerak() { document.title=txt;
txt=txt.substring(1,txt.length)+txt.charAt(0);
segarkan=setTimeout("bergerak()",kecepatan);}bergerak();
</script>
<style type="text/css">
<!--
.style1 {color: #3366FF}
-->
</style>
</head>
<body>
<form action="simpan.php" method="post"
name="form1" target="_self">
<table width="494" border="0" cellpadding="2"
cellspacing="1">
<tr align="center" bgcolor="#CCFF66">
<td colspan="2"><b>PENDAFTARAN KTP</b></td>
</tr>
<tr>
<td width="121" align="left" bgcolor="#99FFFF"><span class="style1">No KTP :</span></td>
<td width="268" bgcolor="#99FFFF"><input name="Txtktp" type="text"
value="<?= $Txtktp; ?>" size="25" maxlength="30"></td>
</tr>
<tr>
<td align="left" bgcolor="#99FFFF"><span class="style1">Nama :</span></td>
<td bgcolor="#99FFFF"><input name="Txtnama" type="text" size="25"
maxlength="100"></td>
</tr>
<tr>
<td align="left" bgcolor="#99FFFF"><span class="style1">Tempat Tanggal Lahir :</span></td>
<td bgcolor="#99FFFF"><input name="Txtttl" type="text" size="25"
maxlength="50"></td>
</tr>
<tr>
<td align="left" bgcolor="#99FFFF"><span class="style1">Kelamin :</span></td>
<td bgcolor="#99FFFF"><span class="style1">
<input name="Rbkelamin" type="radio" value="P"
checked>
Laki-laki
<input type="radio" name="Rbkelamin" value="W">
Perempuan</span></td>
</tr>
<tr>
<td align="left" bgcolor="#99FFFF"><span class="style1">Alamat : </span></td>
<td bgcolor="#99FFFF"><span class="style1">
<textarea name="TxtAlamat" cols="30" rows="2"><?=
$TxtAlamat; ?>
</textarea>
</span></td>
</tr>
<tr>
<td align="left" bgcolor="#99FFFF"><span class="style1">RT / RW :</span></td>
<td bgcolor="#99FFFF"><input name="Txtrt" type="text" value="<?=
$Txtrt; ?>" size="25" maxlength="8"></td>
</tr>
<tr>
<td align="left" bgcolor="#99FFFF"><span class="style1">Desa / Kelurahan:</span></td>
<td bgcolor="#99FFFF"><input name="Txtdesa" type="text" value="<?=
$Txtdesa; ?>" size="25" maxlength="25"></td>
</tr>
<tr>
<td align="left" bgcolor="#99FFFF"><span class="style1">Kecamatan :</span></td>
<td bgcolor="#99FFFF"><input name="Txtkec" type="text" value="<?=
$Txtkec; ?>" size="35" maxlength="25"></td>
</tr>
<tr>
<td align="left" bgcolor="#99FFFF"><span class="style1">Kab / Kota :</span></td>
<td bgcolor="#99FFFF"><input name="Txtkota" type="text" value="<?=
$Txtkota; ?>" size="25" maxlength="25"></td>
</tr>
<tr>
<td align="left" bgcolor="#99FFFF"><span class="style1">Agama :</span></td>
<td bgcolor="#99FFFF"><span class="style1">
<input name="Rbagama" type="radio" value="i"
checked>
Islam
<input type="radio" name="Rbagama" value="n">
Nasrani
<input type="radio" name="Rbagama" value="b">
Budha
<input type="radio" name="Rbagama" value="h">
Hindu</span></td>
</tr>
<tr>
<td align="left" bgcolor="#99FFFF"><span class="style1">Status Perkawinan :</span></td>
<td bgcolor="#99FFFF"><span class="style1">
<input name="Rbstatus" type="radio" value="k"
checked>
Kawin
<input type="radio" name="Rbstatus" value="b">
Belum Kawin</span></td>
</tr>
<tr>
<td align="left" bgcolor="#99FFFF"><span class="style1">Pekerjaan :</span></td>
<td bgcolor="#99FFFF"><input name="Txtkerja" type="text" value="<?=
$Txtkerja; ?>" size="35" maxlength="25"></td>
</tr>
<tr>
<td align="left" bgcolor="#99FFFF"><span class="style1">Berlaku Hingga :</span></td>
<td bgcolor="#99FFFF"><input name="Txtberlaku" type="text" value="<?=
$Txtberlaku; ?>" size="35" maxlength="25"></td>
</tr>
<tr>
<td> </td>
<td><input type="submit" name="Submit" value="Daftar
Sekarang"></td>
</tr>
<td colspan="2"> <MARQUEE behavior=alternate direction=left>
<span class="style1">UTS. R Welly Trijatno Putro</span>
</MARQUEE></td>
</table>
</form>
</body>
</html>
panjang ya...
nanti seperti ini hasilnya
