mirror of
https://codeberg.org/angestoepselt/refund-form.git
synced 2025-05-24 14:46:16 +00:00
98 lines
No EOL
4.2 KiB
HTML
98 lines
No EOL
4.2 KiB
HTML
<!DOCTYPE html>
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<html lang="de">
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<head>
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<meta charset="utf-8">
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<meta http-equiv="X-UA-Compatible" content="IE=edge">
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<meta name="viewport" content="width=device-width, initial-scale=1">
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<title>Bestätigung von Auslagen</title>
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<link href="assets/vendor/bootstrap/css/bootstrap.min.css" rel="stylesheet">
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<link href="assets/css/main.css" rel="stylesheet">
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<!--[if lt IE 9]>
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<script src="https://oss.maxcdn.com/html5shiv/3.7.3/html5shiv.min.js"></script>
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<script src="https://oss.maxcdn.com/respond/1.4.2/respond.min.js"></script>
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<![endif]-->
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</head>
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<body>
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<main>
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<div class="container">
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<header class="d-flex flex-wrap justify-content-center py-3 mb-4 border-bottom">
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<a href="/" class="d-flex align-items-center mb-4 mb-md-0 ms-md-auto text-dark text-decoration-none">
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<img src="assets/img/angestöpselt_logo_web.jpg" alt="Angestöpselt" title="Angestöpselt" width="400" height="62.5">
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</a>
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</header>
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<div class="row">
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<div class="row justify-content-md-center">
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<div class="col col-12 col-lg-8">
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<h1>Bestätigung von Auslagen</h1>
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<div class="mt-5">
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<form>
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<div class="mb-4">
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<label for="name" class="form-label">Name *</label>
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<input id="name" name="name" type="text" class="form-control" required="required" />
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</div>
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<div class="mb-4">
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<label for="adresse" class="form-label">Adresse *</label>
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<textarea id="adresse" name="adresse" cols="40" rows="2" class="form-control" required="required"></textarea>
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</div>
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<div class="mb-4">
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<label class="form-label">Erbrachte Leistungen</label>
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<div id="form-leistung-wrapper">
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<div id="form-leistung" class="form-leistung position-relative mb-3">
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<div class="row">
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<div class="col col-10">
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<input id="leistung_0" name="leistung_0" type="text" class="leistung form-control" />
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</div>
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<div class="col col-2">
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<input id="betrag_0" name="betrag_0" type="text" class="betrag form-control" />
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</div>
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</div>
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<span class="btn-minus position-absolute">−</span>
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</div>
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</div>
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<div class="row">
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<div class="col-2 ms-auto">
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<input id="gesamt" name="gesamt" type="text" class="form-control" readonly="readonly" />
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</div>
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</div>
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<span class="btn-plus ms-auto mt-3">＋</span>
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</div>
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<div class="form-check mb-4">
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<input name="verzicht" id="verzicht" type="checkbox" class="form-check-input" value="verzicht" />
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<label for="verzicht" class="form-check-label">Ich verzichte auf die Erstattung des Betrages und spende ihn stattdessen</label>
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</div>
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<div class="form-check mb-4">
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<input name="auszahlung" id="auszahlung" type="checkbox" class="form-check-input" value="auszahlung" />
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<label for="auszahlung" class="form-check-label">Ich bitte um Auszahlung des Betrages per Banküberweisung auf mein Konto:</label>
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</div>
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<div id="form-iban" class="form-group mb-4">
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<label for="iban" class="form-label">IBAN</label>
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<input id="iban" name="iban" type="text" class="form-control" />
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</div>
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<br>
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<div class="mb-4">
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<label for="citydate" class="form-label">Ort, Datum *</label>
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<input id="citydate" name="citydate" type="text" class="form-control" required="required" />
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</div>
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<div class="mb-4">
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<div class="btn btn-primary btn-continue">Weiter</div>
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</div>
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</form>
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</div>
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</div>
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</div>
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</div>
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</div>
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</main>
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<script src="assets/vendor/jquery/jquery-3.7.1.min.js"></script>
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<script src="assets/vendor/bootstrap/js/bootstrap.bundle.min.js"></script>
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<script src="assets/js/main.js"></script>
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</body>
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</html> |