<table border="0" cellspacing="0" cellpadding="1" align="center" bgcolor="#666699">
  <tr align="center">
    <td>
     <style type="text/css">
      <!--
       .button {  font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 8pt}
       .textarea {  font-family: "MS Sans Serif"; font-size: 9pt; width: 195px}
       .input {  width: 195px}
      -->
    </style><font color="#FFFFFF" face="Verdana, Arial, Helvetica, sans-serif" size="2"><b>Submit Your Comment</b></font></td>
  </tr>
  <tr>
    <td>
      <table border="0" cellspacing="0" cellpadding="5" align="center" bgcolor="#FFFFFF" width="200">
        <tr>
          <td width="149">
            <form method="post" action="$this->form_forward">
              <table border="0" cellspacing="0" cellpadding="2" bgcolor="" align="center">
                <tr>
                  <td class="td1" height="40"><b><font face="Verdana, Arial, Helvetica, sans-serif" size="1">$question</font></b></td>
                </tr>
                <tr>
                  <td class="td1"><font face="Verdana, Arial, Helvetica, sans-serif" size="1">Name:</font><br>
                    <input type="text" name="name" maxlength="25" class="input" size="23">
                  </td>
                </tr>
                <tr>
                  <td class="td1"><font face="Verdana, Arial, Helvetica, sans-serif" size="1">e-mail:</font><br>
                    <input type="text" name="email" size="23" maxlength="50" class="input">
                  </td>
                </tr>
                <tr>
                  <td class="td1"><font face="Verdana, Arial, Helvetica, sans-serif" size="1">Comment(*):</font><br>
                    <font face="MS Sans Serif" size="1">
                    <textarea name="message" cols="19" wrap="VIRTUAL" rows="6" class="textarea"></textarea>
                    </font>
                  </td>
                </tr>
                <tr valign="top">
                  <td>
                    <input type="submit" value="Submit" class="button">
                    <input type="reset" value="Reset" class="button">
                    <input type="hidden" name="action" value="add">
                    <input type="hidden" name="id" value="$poll_id">
                  </td>
                </tr>
              </table>
            </form>
          </td>
        </tr>
      </table>
    </td>
  </tr>
</table>