<!DOCTYPE html>
<html lang="en">
<head>
  <meta charset="utf-8">
  <title>Drop off laundry &mdash; Profitina Laundry</title>
</head>
<body>
  <h1>Drop off laundry</h1>
  <form method="post" action="">
    <p><label>Name <input name="name" value="&lt;script&gt;alert(1)&lt;/script&gt;"></label>
       <span class="error">Use 2 to 60 letters; spaces, dots, apostrophes and hyphens are allowed.</span>
    </p>
    <p><label>Phone <input name="phone" value="12345"></label>
       <span class="error">Use an Indonesian mobile number such as 0812-3456-7890.</span>
    </p>
    <p><label>Service <select name="service">
      <option value="S0001">Wash, dry &amp; fold</option>
      <option value="S0002">Express wash &amp; fold, 1 day</option>
      <option value="S0003">Ironing only</option>
      <option value="S0008" selected>Bed cover, any size</option>
    </select></label>
    </p>
    <p><label>Quantity <input name="qty" value="1,5"></label>
       <span class="error">Items are counted in whole numbers.</span>
    </p>
    <p><button>Create bill</button></p>
  </form>
</body>
</html>
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