<div align='left'>
  <table border='0' cellpadding='0' cellspacing='0' width='191' height='153'>
    <tr>
      <td width='191' height='153'><form method='POST' action='mailto:un@wp.pl'>
<p align='right'>
Adres strony: <input type='text' value='http://' name='wiadomosc' style='color: #000000; background-color: #FFFFFF; font-size: 7pt; font-family: Verdana; width: 100px; height: 19px; border-style: groove; border-color: #000000; border-width: 1px'>
<br>Wiek strony: <input type='text' name='wiadomosc1' style='color: #000000; background-color: #FFFFFF; font-size: 7pt; font-family: Verdana; width: 100px; height: 19px; border-style: groove; border-color: #000000; border-width: 1px'>
<br>Statystyki: <input type='text' name='wiadomosc2' style='color: #000000; background-color: #FFFFFF; font-size: 7pt; font-family: Verdana; width: 100px; height: 19px; border-style: groove; border-color: #000000; border-width: 1px'>
<br>Miejsce: <input type='text' name='wiadomosc3' style='color: #000000; background-color: #FFFFFF; font-size: 7pt; font-family: Verdana; width: 100px; height: 19px; border-style: groove; border-color: #000000; border-width: 1px'>
<br><br>
<center><input type='submit' value='Wy¶lij' style='color: #000000; background-color: #FFFFFF; font-size: 7pt; font-family: Verdana; width: 50px; height: 19px; border-style: groove; border-color: #000000; border-width: 1px'></center>
</form></td>
    </tr>
  </table>
</div>