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document.write('<form action="//ashita-sanuki.jp/survey_result.php" method="post"><input type="hidden" name="csrf" value="4eafc9c55201e01574821ab72d0c52e71bde5500" />');
document.write('<div id="survey_title">');
document.write('レンタルビデオ店の利用頻度調査');
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document.write('<div id="survey_time">2009/01/05～2009/01/31</div>');
document.write('<div id="survey_brief">レンタルビデオ店を利用する頻度を教えて下さい。<br />ビデオ、ＤＶＤ、ＣＤ何を主にレンタルされますか？<br />良く見るジャンルは何かなどコメントに入力して下さい。</div>');
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document.write('<tr class="survey_vote"><td class="survey_vote"></td><td class="survey_vote"><label for="0">週１回以上</label></td></tr><tr class="survey_vote"><td class="survey_vote"></td><td class="survey_vote"><label for="1">月に１回程度</label></td></tr><tr class="survey_vote"><td class="survey_vote"></td><td class="survey_vote"><label for="2">月に２～３回程度</label></td></tr><tr class="survey_vote"><td class="survey_vote"></td><td class="survey_vote"><label for="3">２～３ヶ月に１回程度</label></td></tr><tr class="survey_vote"><td class="survey_vote"></td><td class="survey_vote"><label for="4">半年に１回程度</label></td></tr><tr class="survey_vote"><td class="survey_vote"></td><td class="survey_vote"><label for="5">年に数回程度</label></td></tr><tr class="survey_vote"><td class="survey_vote"></td><td class="survey_vote"><label for="6">ここ数年はレンタルを利用していない</label></td></tr><tr class="survey_vote"><td class="survey_vote"></td><td class="survey_vote"><label for="7">レンタルを利用した事はない</label></td></tr>');
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document.write('<p class="more"><a href="//ashita-sanuki.jp/survey_result.php?id=24&page=2">投票結果を見る</a></p>');
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document.write('<input type="hidden" name="id" value="24">');
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