Also include some type of input where people can request a date and time. This could be a textarea, text field, or (if you're feeling ambitious), a date picker. If you do the date picker, feel free to borrow code from other places online to implement it.
Use the reflector.cgi for the action of the form so we can both be sure your data is being submitted correctly.
Upload your files to your INST671/hw4 folder and name your main page index.html.