<fieldset>
<legend>服务反馈</legend>
<p>
<label>评分:</label>
<input type="radio" name="score" value="5" id="s5"><label for="s5">非常满意</label>
<input type="radio" name="score" value="4" id="s4"><label for="s4">满意</label>
<input type="radio" name="score" value="3" id="s3"><label for="s3">一般</label>
</p>
<p>
<label for="feedback">反馈内容:</label>
<textarea id="feedback" name="feedback" rows="5" maxlength="200"></textarea>
</p>
</fieldset>
<button type="submit">提交反馈</button>