<?php
$current_month = date("F");
$current_date = date("d");
$current_year = date("Y");
$current_time = date("H:i");
?>

<form method="post" action="<?php echo $_SERVER['PHP_SELF']; ?>">

<p><strong><label for="month">Date (month, day, year):</label></strong>

<select name="month" id="month">
<option value="<?php echo $current_month; ?>"><?php echo $current_month; ?></option>
<option value="January">January</option>
<option value="February">February</option>
<option value="March">March</option>
<option value="April">April</option>
<option value="May">May</option>
<option value="June">June</option>
<option value="July">July</option>
<option value="August">August</option>
<option value="September">September</option>
<option value="October">October</option>
<option value="November">November</option>
<option value="December">December</option>
</select>

<input type="text" name="date" id="date" size="2" value="<?php echo $current_date; ?>" />

<select name="year" id="year">
<option value="<?php echo $current_year; ?>"><?php echo $current_year; ?></option>
<option value="2004">2004</option>
<option value="2005">2005</option>
<option value="2006">2006</option>
<option value="2007">2007</option>
<option value="2008">2008</option>
<option value="2009">2008</option>
<option value="2010">2010</option>
</select>

<strong><label for="time">Time:</label></strong> <input type="text" name="time" id="time" size="5" value="<?php echo $current_time; ?>" /></p>

<p><strong><label for="title">Title:</label></strong> <input type="text" name="title" name="title" size="40" /></p>

<p><textarea cols="80" rows="20" name="entry" id="entry"></textarea></p>

<p><input type="submit" name="submit" id="submit" value="Submit"></p>

</form>