index.php

<html>



<head>

<link rel="shortcut icon" type="image/x-icon" href="http://URL_ZUR_ANWENDUNG/impfanmeldung/favicon.ico">

<?php

require_once ('konfiguration.php');
$db_link = mysqli_connect (
                     MYSQL_HOST, 
                     MYSQL_BENUTZER, 
                     MYSQL_KENNWORT, 
                     MYSQL_DATENBANK
                    );
					
$myServer = 'http://URL_ZUR_ANWENDUNG/impfanmeldung';


$fileWriteNachname = '';
$fileWriteVorname = '';
$fileWriteStrasse = '';
$fileWritePLZ = '';
$fileWriteOrt = '';
$fileWriteGebDatum = '';
$fileWriteHandynr = '';
$fileWritePrivPhoneNumber = '';
$fileWritePrivMail = '';
$fileWriteWorkPhoneNumber = '';
$fileWriteWorkMail = '';
$fileWriteWorkTime = '';
$fileWriteOtgEinheit = '';
$fileWriteAnmeldedatum = '';


if(isset($_POST['fileWriteName']) && !empty($_POST['fileWriteName'])) {

$fileWriteNachname = $_POST['fileWriteName'];
$fileWriteVorname = $_POST['fileWriteVorname'];
$fileWriteStrasse = $_POST['fileWriteStreet'];
$fileWritePLZ = $_POST['fileWritePLZ'];
$fileWriteOrt = $_POST['fileWriteOrt'];
$fileWriteGebDatum = $_POST['fileWriteGeburtsdatum'];
$fileWriteHandynr = $_POST['fileWriteHandynummer'];
$fileWritePrivPhoneNumber = $_POST['fileWritePrivNumber'];
$fileWritePrivMail = $_POST['fileWritePrivMail'];
$fileWriteWorkPhoneNumber = $_POST['fileWriteWorkNumber'];
$fileWriteWorkMail = $_POST['fileWriteWorkMail'];
$fileWriteWorkTime = $_POST['fileWriteWorkTime'];
$fileWriteOtgEinheit = $_POST['fileWriteOrg'];
$fileWriteAnmeldedatum = $datum = date('d.m.Y');


}
if($fileWriteNachname) {

$sql = "
  INSERT INTO `coronaimpfung`
  (`nachname` , `vorname` , `strasse` , `plz` , `ort` , `gebdatum` , `handynr` , `privphonenr` , `privmail` , `workphonenr` , `workmail` , `arbeitszeitmodell` , `orgeinheit` , `anmeldedatum` ) 
  VALUES
	('".$fileWriteNachname."', '".$fileWriteVorname."', '".$fileWriteStrasse."', '".$fileWritePLZ."', '".$fileWriteOrt."', '".$fileWriteGebDatum."', '".$fileWriteHandynr."', '".$fileWritePrivPhoneNumber."', '".$fileWritePrivMail."', '".$fileWriteWorkPhoneNumber."', '".$fileWriteWorkMail."', '".$fileWriteWorkTime."', '".$fileWriteOtgEinheit."', '".$fileWriteAnmeldedatum."');";
	
$db_erg = mysqli_query($db_link, $sql) 
   or die("Anfrage fehlgeschlagen: " . mysqli_error($db_link));

header('refresh: 1; url='.$myServer.'/thanks.html'); 
}

?>



</head>



<body>

<meta charset="utf-8" />
    <meta http-equiv="Content-type" content="text/html; charset=utf-8" />
    <meta name="viewport" content="width=device-width, initial-scale=1" />
    <style type="text/css">
    body {
        background-color: #f0f0f2;
        margin: 0;
        padding: 0;
        font-family: -apple-system, system-ui, BlinkMacSystemFont, "Segoe UI", "Open Sans", "Helvetica Neue", Helvetica, Arial, sans-serif;
        
    }
    div {
        width: 600px;
        margin: 5em auto;
        padding: 2em;
        background-color: #fdfdff;
        border-radius: 0.5em;
        box-shadow: 2px 3px 7px 2px rgba(0,0,0,0.02);
    }
    a:link, a:visited {
        color: #38488f;
        text-decoration: none;
    }
    @media (max-width: 700px) {
        div {
            margin: 0 auto;
            width: auto;
        }
    }
	
	.button {
		box-shadow:inset 0px 1px 0px 0px #d9fbbe;
		background:linear-gradient(to bottom, #b8e356 5%, #a5cc52 100%);
		background-color:#b8e356;
		border-radius:6px;
		border:1px solid #83c41a;
		display:inline-block;
		cursor:pointer;
		color:#ffffff;
		font-family:Arial;
		font-size:15px;
		font-weight:bold;
		padding:6px 24px;
		text-decoration:none;
		text-shadow:0px 1px 0px #86ae47;
	}
	.button:hover {
		background:linear-gradient(to bottom, #a5cc52 5%, #b8e356 100%);
		background-color:#a5cc52;
	}
	.button:active {
		position:relative;
		top:1px;
	}
	
		input[type=button], input[type=submit], input[type=reset] {
		background-color: #27428E;
		border: none;
		color: white;
		padding: 16px 32px;
		text-decoration: none;
		margin: 4px 2px;
		cursor: pointer;
	}
	
	#myInput {
		background-image: url('/css/searchicon.png');
		background-position: 10px 10px;
		background-repeat: no-repeat;
		width: 90%;
		font-size: 16px;
		padding: 12px 20px 12px 40px;
		border: 1px solid #ddd;
		margin-bottom: 12px;
	}

	#myTable {
		border-collapse: collapse;
		width: 100%;
		border: 1px solid #ddd;
		font-size: 18px;
	}

	#myTable th, #myTable td {
		text-align: left;
	padding: 12px;
	}

	#myTable tr {
		border-bottom: 1px solid #ddd;
	}

	#myTable tr.header, #myTable tr:hover {
		background-color: #f1f1f1;
	}
	
    </style>  

<div>
<img src="MEIN_LOGO.jpg" alt="Mein Logo" align=center>
<h1>Vormerkung zur Corona-Impfung</h1>
<p>Hier könnte Ihr Text stehen!</p>
<br/>
<form id="some" name="someName" method="post">
Name: <br/><input type="text" id="name" class="someClass" size="80" value="" name="fileWriteName"/><br/>
Vorname: <br/><input type="text" id="vorname" class="someClass" size="80" value="" name="fileWriteVorname"/><br/>
Straße und Hausnummer: <br/><input type="text" id="vorname" class="someClass" size="80" value="" name="fileWriteStreet"/><br/>
Postleitzahl: <br/><input type="text" id="vorname" class="someClass" size="80" value="" name="fileWritePLZ"/><br/>
Wohnort: <br/><input type="text" id="vorname" class="someClass" size="80" value="" name="fileWriteOrt"/><br/>
Geburtsdatum: <br/><input type="text" id="vorname" class="someClass" size="80" value="" name="fileWriteGeburtsdatum"/><br/>
Handynummer: <br/><input type="text" id="vorname" class="someClass" size="80" value="" name="fileWriteHandynummer"/><br/>
private Rufnummer: <br/><input type="text" id="privatecallnr" class="someClass" size="80" value="" name="fileWritePrivNumber"/><br/>
private Mail Adresse: <br/><input type="text" id="privatemail" class="someClass" size="80" value="" name="fileWritePrivMail"/><br/>
dienstliche Rufnummer: <br/><input type="text" id="vorname" class="someClass" size="80" value="" name="fileWriteWorkNumber"/><br/>
dienstliche Mail Adresse: <br/><input type="text" id="workmail" class="someClass" size="80" value="" name="fileWriteWorkMail"/><br/>
Organisationseinheit: <br/><input type="text" id="workmail" class="someClass" size="80" value="" name="fileWriteOrg"/><br/>
Anwesenheit/Arbeitszeitmodell (z.B.: ungerade Wochen oder Mo., Mi., Fr. oder ähnlich): <br/><input type="text" id="workmail" class="someClass" size="80" value="" name="fileWriteWorkTime"/><br/>
<br/>
<input type="submit" value="absenden" class="submitClass"/>
</form>
<br/>
<p><i>Haben Sie bitte nach dem Absenden etwas Geduld. Bei einer erfolgreichen Eintragung werden Sie weitergeleitet.</i></p>
</div>
</body>
</html>