Your question is unclear.
Please provide more information, and be as specific as possible.
- What do you want to accomplish?
- What have you already tried?
- What problems did you encounter?
Also, please be sure that you have included all relevant code and/or a link to the page in question.
- What information do you want to collect from users?
- What do you want to do with the information afterwards?
- If this is the actual form you're using, what do you want to happen when you submit it?
- What server-side language do you plan to use?
As it stands, you question is far too vague to answer. It's okay that you don't know how to do it, but please be as specific as possible when describing what you want to do.