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form-penyedia-vaksin.html
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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8" />
<meta name="viewport" content="width=device-width, initial-scale=1.0" />
<!-- SEO Meta Tags -->
<meta name="description" content="Website AyoVaksin menyediakan..." />
<meta name="author" content="AyoVaksin" />
<meta
name="keywords"
content="AyoVaksin,ayovaksin,vaksin,vaksinindonesia,covid19,vaksincovid19"
/>
<!-- OG Meta Tags to improve the way the post looks when you share the page on Facebook, Twitter, LinkedIn -->
<meta property="og:site_name" content="AyoVaksin" />
<!-- website name -->
<meta property="og:site" content="" />
<!-- website link -->
<meta property="og:title" content="AyoVaksin" />
<!-- title shown in the actual shared post -->
<meta property="og:description" content="Website AyoVaksin menyediakan" />
<!-- description shown in the actual shared post -->
<meta property="og:image" content="" />
<!-- image link, make sure it's jpg -->
<meta property="og:url" content="" />
<!-- where do you want your post to link to -->
<meta name="twitter:card" content="summary_large_image" />
<!-- to have large image post format in Twitter -->
<!-- Webpage Title -->
<title>Form Bantu Vaksinasi | AyoVaksin</title>
<!-- apple touch icon -->
<link
rel="apple-touch-icon"
sizes="57x57"
href="assets/img/icon/apple-touch-icon-57x57.png"
/>
<link
rel="apple-touch-icon"
sizes="72x72"
href="assets/img/icon/apple-touch-icon-72x72.png"
/>
<link
rel="apple-touch-icon"
sizes="76x76"
href="assets/img/icon/apple-touch-icon-76x76.png"
/>
<link
rel="apple-touch-icon"
sizes="114x114"
href="assets/img/icon/apple-touch-icon-114x114.png"
/>
<link
rel="apple-touch-icon"
sizes="120x120"
href="assets/img/icon/apple-touch-icon-120x120.png"
/>
<link
rel="apple-touch-icon"
sizes="144x144"
href="assets/img/icon/apple-touch-icon-144x144.png"
/>
<link
rel="apple-touch-icon"
sizes="180x180"
href="assets/img/icon/apple-touch-icon-180x180.png"
/>
<!-- Styles -->
<link
href="https://cdn.jsdelivr.net/npm/bootstrap@5.1.3/dist/css/bootstrap.min.css"
rel="stylesheet"
integrity="sha384-1BmE4kWBq78iYhFldvKuhfTAU6auU8tT94WrHftjDbrCEXSU1oBoqyl2QvZ6jIW3"
crossorigin="anonymous"
/>
<!-- bootstrap styles -->
<link
rel="stylesheet"
href="https://cdnjs.cloudflare.com/ajax/libs/bootstrap-icons/1.5.0/font/bootstrap-icons.min.css"
integrity="sha512-xnP2tOaCJnzp2d2IqKFcxuOiVCbuessxM6wuiolT9eeEJCyy0Vhcwa4zQvdrZNVqlqaxXhHqsSV1Ww7T2jSCUQ=="
crossorigin="anonymous"
referrerpolicy="no-referrer"
/>
<!-- bootstrap icon -->
<link
rel="stylesheet"
href="https://cdnjs.cloudflare.com/ajax/libs/animate.css/4.1.1/animate.min.css"
/>
<!-- animate animation styles -->
<link
rel="stylesheet"
href="assets/vendor/uicons-bold-rounded/css/uicons-bold-rounded.css"
/>
<!-- flaticon bold rounded icon styles -->
<link rel="stylesheet" href="assets/vendor/icofont/icofont.css" />
<!-- icofont styles icon -->
<link
rel="stylesheet"
href="https://cdnjs.cloudflare.com/ajax/libs/font-awesome/6.0.0-beta3/css/all.min.css"
integrity="sha512-Fo3rlrZj/k7ujTnHg4CGR2D7kSs0v4LLanw2qksYuRlEzO+tcaEPQogQ0KaoGN26/zrn20ImR1DfuLWnOo7aBA=="
crossorigin="anonymous"
referrerpolicy="no-referrer"
/>
<!-- font-awesome styles icon -->
<!-- custom styles -->
<link rel="stylesheet" href="assets/css/styles.css" />
<!-- Favicon -->
<link rel="icon" href="assets/img/icon/favicon.ico" />
</head>
<body>
<!-- navigation -->
<div class="nav__section position-sticky">
<nav class="navbar navbar-expand-lg navbar-light navbar__expand">
<div class="container-fluid nav__fluid">
<a class="navbar-brand" href="index.html">
<img
src="assets/img/logo-nav.svg"
alt="ayo-vaksin-logo-nav"
class="brand__logo"
/></a>
<!-- end navbar brand -->
<button
class="navbar-toggler shadow-none"
type="button"
data-bs-toggle="collapse"
data-bs-target="#navbarNav"
aria-controls="navbarNav"
aria-expanded="false"
aria-label="Toggle navigation"
>
<i class="fi fi-br-menu-burger"></i>
</button>
<!-- end menu btn -->
<div class="collapse navbar-collapse" id="navbarNav">
<ul class="navbar-nav navbar__nav ms-auto">
<li class="nav-item nav__item">
<a
class="nav-link nav__link"
aria-current="page"
href="index.html"
><span>Home</span></a
>
</li>
<li class="nav-item nav__item">
<a class="nav-link nav__link" href="alur.html"
><span>Alur</span></a
>
</li>
<li class="nav-item nav__item">
<a class="nav-link nav__link" href="daftar-vaksin.html"
><span>Daftar Vaksin</span></a
>
</li>
<li class="nav-item nav__item">
<a class="nav-link nav__link" href="kebijakan-privasi.html"
><span>Kebijakan Privasi</span></a
>
</li>
</ul>
<!-- end navbar nav -->
<div class="navbar-nav">
<a href="login-akun.html" class="nav-link nav__link btn__nav"
>Login</a
>
</div>
<!-- end navbar nav btn nav -->
</div>
<!-- end nav collapse -->
</div>
<!-- end container -->
</nav>
<!-- end nav -->
</div>
<!-- end nav section -->
<!-- header section -->
<div class="header__section">
<div class="container">
<div class="header__content">
<h1 class="header__mb">Form Mitra Vaksin</h1>
<p class="desc__header">
Bantu kami untuk meperluas dan mempercepat vaksinasi di Indonesia
agar semua orang dapat terhindar dari Covid-19.
</p>
</div>
<!-- end header content -->
</div>
<!-- end container -->
</div>
<!-- end header section -->
<!-- form section -->
<div class="av__b">
<div class="container">
<div class="signin__section">
<div class="row">
<div class="col-12">
<form method="post" class="row g-3 mb-4">
<div class="col-12 my-2">
<label
for="namaInstansi"
class="form-label form__label mt-2 mb-sm-3 mb-2"
>Nama Instansi</label
>
<input
type="text"
class="form-control form__control shadow-none"
id="namaInstansi"
placeholder="Masukkan Nama Instansi"
required
/>
</div>
<div class="col-sm-6 col-12 my-2">
<label
for="tglPelaksanaan"
class="form-label form__label mt-2 mb-sm-3 mb-2"
>Tanggal Pelaksanaan</label
>
<input
type="date"
class="form-control form__control shadow-none"
id="tglPelaksanaan"
required
/>
</div>
<div class="col-sm-6 col-12 my-2">
<label
for="noTelepon"
class="form-label form__label mt-2 mb-sm-3 mb-2"
>Nomor Telepon</label
>
<input
type="text"
class="form-control form__control shadow-none"
id="noTelepon"
placeholder="Masukkan Nomor Telepon Aktif"
required
/>
</div>
<div class="col-12 my-2">
<label class="form-label form__label mt-2 mb-sm-3 mb-2"
>Jenis Vaksin</label
>
<select class="form-select shadow-none form__control">
<option selected disabled>Pilih Jenis Vaksin</option>
<option value="astrazeneca">AstraZeneca Vaccine</option>
<option value="sinovac">Sinovac-CoronaVac</option>
<option value="pfizer">Pfizer-BioNTech</option>
<option value="moderna">Moderna Vaccine</option>
</select>
</div>
<div class="col-sm-6 col-12 my-2">
<label
for="dosis"
class="form-label form__label mt-2 mb-sm-3 mb-2"
>Jumlah Dosis</label
>
<input
type="number"
class="form-control form__control shadow-none"
id="dosis"
placeholder="Masukkan Jumlah Dosis"
required
/>
</div>
<div class="col-sm-6 col-12 my-2">
<label class="form-label form__label mt-2 mb-sm-3 mb-2"
>Pilih Doses Ke-</label
>
<select class="form-select shadow-none form__control">
<option selected disabled>Pilih Dosis Ke-</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
</select>
</div>
<div class="col-12 my-2">
<label
for="alamat"
class="form-label form__label mt-2 mb-sm-3 mb-2"
>Alamat Lengkap</label
>
<textarea
name="alamat"
id="alamat"
cols="30"
rows="5"
class="form-control form__control shadow-none"
placeholder="Masukkan alamat lengkap..."
></textarea>
</div>
<div
class="col-12 mt-4 d-flex justify-content-center align-items-center"
>
<input type="submit" class="btn kp__btn" value="Daftar" />
</div>
</form>
</div>
</div>
<!-- end row -->
</div>
<!-- end sign in section -->
</div>
<!-- end container -->
</div>
<!-- end form section -->
<!-- footer -->
<footer
class="foot"
style="
background: linear-gradient(
0deg,
rgba(38, 86, 190, 0.9),
rgba(38, 86, 190, 0.9)
),
url(assets/img/bg-footer.png);
"
>
<div class="container">
<div class="footer__section">
<div class="row foot__top">
<div class="col-sm-4 col-12 flex">
<a
href="index.html"
class="d-flex justify-content-start align-items-center"
>
<img
class="foot__img"
src="assets/img/logo-foot.svg"
alt="..."
/>
</a>
</div>
<!-- end img foot -->
<div class="col-sm-8 col-12 d-flex justify-content-end">
<div class="foot__content">
<p>
AyoVaksin dikembangkan untuk melayani masyarakat dalam rangka
menghentikan rantai Coronavirus Disease (COVID-19). Kami
membantu instansi-instansi yang terkait dalam program
vaksinasi di Indonesia. Menjadikan proses vaksinasi berjalan
lancar dan merata demi terwujudnya Indonesia bebas corona.
</p>
<a class="main__btn btn__saran mt-3" href="saran.html"
>Kotak Saran</a
>
</div>
</div>
<!-- end desc foot -->
</div>
<!-- end foot top -->
<hr style="border: 1px solid rgba(242, 244, 248, 1)" />
<div class="row pt-2 foot__bottom">
<div class="col-md-6 col-sm-12 flex__left">
<ul class="foot__navlink">
<li>
<a href="index.html">Home</a>
</li>
<li>
<a href="alur.html">Alur</a>
</li>
<li>
<a href="daftar-vaksin.html">Daftar Vaksin</a>
</li>
<li>
<a href="kebijakan-privasi.html">Kebijakan Privasi</a>
</li>
</ul>
<p class="font__second">Save yourself to save others.</p>
</div>
<!-- end left -->
<div class="col-md-6 col-sm-12 flex__right">
<div class="foot__icon mb-3">
<a href="#" class="d-flex align-items-center">
<img
src="assets/img/instagram-icon.svg"
height="20"
alt="..."
/>
</a>
<a href="#" class="d-flex align-items-center ms">
<i class="icofont-linkedin"></i>
</a>
<a href="#" class="d-flex align-items-center ms">
<i class="icofont-youtube-play"></i>
</a>
</div>
<p class="font__second" style="font-size: 14px">
© AyoVaksin. All rights reserved.
</p>
</div>
<!-- end right -->
</div>
<!-- end foot bottom -->
</div>
<!-- end footer section -->
</div>
<!-- end container -->
</footer>
<!-- end footer -->
<!-- scroll up button -->
<i class="bi bi-caret-up-fill scroll__up"></i>
<!-- end scroll up button -->
<!-- scripts -->
<script src="https://ajax.googleapis.com/ajax/libs/jquery/3.5.1/jquery.min.js"></script>
<!-- jquery 3.5.1 Gcdn scripts -->
<script
src="https://cdn.jsdelivr.net/npm/bootstrap@5.1.3/dist/js/bootstrap.bundle.min.js"
integrity="sha384-ka7Sk0Gln4gmtz2MlQnikT1wXgYsOg+OMhuP+IlRH9sENBO0LRn5q+8nbTov4+1p"
crossorigin="anonymous"
></script>
<!-- bootstrap scripts -->
<script src="assets/js/scripts.js"></script>
<!-- Custom scripts -->
</body>
</html>