<tr>
<td>Roll no.:</td>
<td><input type="text" maxlength="15"></td>
</tr>
<tr>
<td>IEN no.:</td>
<td><input type="text" maxlength="30"></td>
</tr>
<tr>
<td>Official college email-id:</td>
<td><input type="text" maxlength="30"></td>
</tr>
<tr>
<td>Contact no.:</td>
<td><input type="text" maxlength="30"></td>
</tr>
<tr>
<td>Year & Department:</td>
<td>
<input class="btn type="radio" name="year">First year
<input class="btn type="radio" name="year">Second year
<input class="btn type="radio" name="year">Third year<br>
<input type="radio" name="dep">Computer
<input type="radio" name="dep">Mechanical
<input type="radio" name="dep">Civil
<input type="radio" name="dep">Electrical
<input type="radio" name="dep">Chemical
</td>
</tr>
<tr>
<td>Comment / Complaint box:</td>
<td>
<textarea name="comm" cols="50" rows="10">
</textarea>
</td>
</tr>
<tr>
<td></td>
<td>
<input type="Submit" name="Submit" value="Submit">
<input type="Reset" name="Reset" value="Reset">
</td>
</tr>
</table>
</form>
</td>
</tr>
</table>