<html>
<head></head>
<body>
<div class="container">
    <div style="text-align:center">
        <h2>Contact Us</h2>
        <p>Swing by for a cup of coffee, or leave us a message:</p>
    </div>
    <div class="row">
        <div class="column">
            <img src="https://static.vecteezy.com/system/resources/thumbnails/019/819/327/small/living-room-with-rattan-furniture-sofa-table-and-lamp-png.png" style="width:100%">
        </div>
        <div class="column">
            <form method="post" action="<?php echo htmlspecialchars($_SERVER["PHP_SELF"]);?>">
                <label for="fname">First Name</label>
                <input type="text" id="fname" name="firstname" placeholder="Your name..">
                <label for="lname">Last Name</label>
                <input type="text" id="lname" name="lastname" placeholder="Your last name..">
                <label for="country">Country</label>
                <select id="country" name="country">
                    <option value="India">India</option>
                    <option value="Canada">Canada</option>
                    <option value="USA">USA</option>
                    <option value="Japan">Japan</option>
                    <option value="China">China</option>
                    <option value="New York">New York</option>
                    <option value="Singapore">Singapore</option>
                    <option value="Dubai">Dubai</option>
                </select>
                <label for="address">Address</label>
                <textarea id="address" name="address" placeholder="Enter your address......." style="height:120px"></textarea>
                <button type="submit">Submit</button>
            </form>
        </div>
    </div>
</div>

</body>
</html>