Código PHP:
<form action="enviar_peticion.php" method="post">
<div id="Layer4"><font color="#FFFFFF" face="Arial">
<select size="1" name="D1">
<option value="Masculino">Masculino</option>
<option value="Femenino">Femenino</option>
</select>
</font></div>
<div id="Layer5"><font color="#FFFFFF" face="Arial">
<select size="1" name="D2">
<option value="10 o menos">10 o menos</option>
<option value="11-12">11-12</option>
<option value="13-14">13-14</option>
<option value="15-16">15-16</option>
<option value="17-18">17-18</option>
</select>
</font></div>
<div id="Layer6"><font color="#FFFFFF" face="Arial"><b>
<select size="1" name="D3">
<option value="Mucho">Mucho</option>
<option value="Poco">Poco</option>
<option value="Nada">Nada</option>
</select>
</b></font></div>
<div id="Layer7"><font color="#FFFFFF"><font face="Arial"><b>
<select size="1" name="D4">
<option value="Siempre">Siempre</option>
<option value="Avance">Aveces</option>
<option value="Nunca">Nunca</option>
</select>
</b></font></font></div>
<div id="Layer8"><font color="#FFFFFF"><b>
<select size="1" name="D5">
<option value="Siempre">Siempre</option>
<option value="Aveces">Aveces</option>
<option value="Nunca">Nunca</option>
</select>
</b></font></div>
<div id="Layer9"><font face="Arial" color="#FFFFFF">
<select size="1" name="D6">
<option value="Si">Si</option>
<option value="No se">No se</option>
<option value="No">No</option>
</select>
</font></div>
<div id="Layer10"><font face="Arial" color="#FFFFFF">
<select name="D7" size="1" id="D7">
<option value="Si">Si</option>
<option value="No se">No se</option>
<option value="No">No</option>
</select>
</font></div>
<div id="Layer11"><font face="Arial" color="#FFFFFF">
<select size="1" name="D8">
<option value="Si">Si</option>
<option value="No se">No se</option>
<option value="No">No</option>>
</select>
</font></div>
<div id="Layer12"><font face="Arial" color="#FFFFFF">
<select name="D9" size="1" id="D9">
<option value="Si">Si</option>
<option value="No se">No se</option>
<option value="No">No</option>
</select>
</font></div>
<div id="Layer13"><font face="Arial" color="#FFFFFF">
<select name="D10" size="1" id="D10">
<option value="Si">Si</option>
<option value="No se">No se</option>
<option value="No">No</option>
</select>
</font></div>
<div id="Layer14"><font face="Arial" color="#FFFFFF">
<select name="D11" size="1" id="D11">
<option value="Si">Si</option>
<option value="No se">No se</option>
<option value="No">No</option>
</select>
</font></div>
<div id="Layer15"><font face="Arial" color="#FFFFFF">
<select name="D12" size="1" id="D12">
<option value="Si">Si</option>
<option value="No se">No se</option>
<option value="No">No</option>
</select>
</font></div>
<div id="Layer16"><font face="Arial" color="#FFFFFF">
<select name="D13" size="1" id="D13">
<option value="Si">Si</option>
<option value="No se">No se</option>
<option value="No">No</option>
</select>
</font></div>
<div id="Layer17"><font face="Arial" color="#FFFFFF">
<select size="1" name="D14">
<option value="Si">Si</option>
<option value="No se">No se</option>
<option value="No">No</option>
</select>
</font></div>
<div id="Layer18"><font face="Arial" color="#FFFFFF">
<select size="1" name="D15">
<option value="Siempre">Siempre</option>
<option value="Aveces">Aveces</option>
<option value="Nunca">Nunca</option>
</select>
</font></div>
<div id="Layer19"><font face="Arial" color="#FFFFFF">
<select size="1" name="D16">
<option value="Si">Si</option>
<option value="Mas o menos">Mas o menos</option>
<option value="No">No</option>
</select>
</font></div>
<div id="Layer20"><font color="#FFFFFF"><span style="font-family: Arial">
<select size="1" name="D17">
<option value="De acuerdo">De acuerdo</option>
<option value="Me da lo mismo">Me da lo mismo</option>
<option value="En desacuerdo">En desacuerdo</option>
</select>
</span></font></div>
<div id="Layer22"><font color="#FFFFFF"><span style="font-size: 12.0pt; font-family: Arial">
<?=$row['respuesta1'];?>
<input type="checkbox" name="C1" value="ON" />
</span></font></div>
<div id="Layer23"><font color="#FFFFFF"><span style="font-size: 12.0pt; font-family: Arial">
<?=$row['respuesta2'];?>
<input name="C2" type="checkbox" id="C2" value="ON" />
</span></font></div>
<div id="Layer24"><font color="#FFFFFF"><span style="font-size: 12.0pt; font-family: Arial">
<?=$row['respuesta3'];?>
<input name="C3" type="checkbox" id="C3" value="ON" />
</span></font></div>
<div id="Layer25"><font color="#FFFFFF"><span style="font-size: 12.0pt; font-family: Arial">
<?=$row['respuesta4'];?>
<input name="C4" type="checkbox" id="C4" value="ON" />
</span></font></div>
<div id="Layer26"><font color="#FFFFFF"><span style="font-size: 12.0pt; font-family: Arial">
<?=$row['respuesta5'];?>
<input name="C5" type="checkbox" id="C5" value="ON" />
</span></font></div>
<div id="Layer27"><font color="#FFFFFF"><span style="font-size: 12.0pt; font-family: Arial">
<?=$row['respuesta6'];?>
<input name="C6" type="checkbox" id="C6" value="ON" />
</span></font></div>
<div id="Layer28"><font color="#FFFFFF"><span style="font-size: 12.0pt; font-family: Arial">
<?=$row['respuesta7'];?>
<input name="C7" type="checkbox" id="C7" value="ON" />
</span></font></div>
<div id="Layer29"><font color="#FFFFFF"><span style="font-size: 12.0pt; font-family: Arial">
<?=$row['respuesta8'];?>
<input name="C8" type="checkbox" id="C8" value="ON" />
</span></font></div>
<div id="Layer30"><font color="#FFFFFF"><span style="font-size: 12.0pt; font-family: Arial">
<?=$row['respuesta9'];?>
<input name="C9" type="checkbox" id="C9" value="ON" />
</span></font></div>
<div id="Layer31"><font color="#FFFFFF"><span style="font-size: 12.0pt; font-family: Arial">
<?=$row['respuesta10'];?>
<input name="C10" type="checkbox" id="C10" value="ON" />
</span></font></div>
<div id="Layer32"><font color="#FFFFFF"><span style="font-size: 12.0pt; font-family: Arial">
<?=$row['respuesta11'];?>
<input name="C11" type="checkbox" id="C11" value="ON" />
</span></font></div>
<div id="Layer33"><font color="#FFFFFF"><span style="font-size: 12.0pt; font-family: Arial">
<?=$row['respuesta12'];?>
<input name="C12" type="checkbox" id="C12" value="ON" />
</span></font></div>
<div id="Layer34"><font color="#FFFFFF"><span style="font-size: 12.0pt; font-family: Arial">
<?=$row['respuesta13'];?>
<input name="C13" type="checkbox" id="C13" value="ON" />
</span></font></div>
<div id="Layer35"><font color="#FFFFFF"><span style="font-size: 12.0pt; font-family: Arial">
<?=$row['respuesta14'];?>
<input name="C14" type="checkbox" id="C14" value="ON" />
</span></font></div>
<div id="Layer36"><font color="#FFFFFF"><span style="font-size: 12.0pt; font-family: Arial">
<?=$row['respuesta15'];?>
<input name="C15" type="checkbox" id="C15" value="ON" />
</span></font></div>
<div id="Layer37"><font color="#FFFFFF"><span style="font-size: 12.0pt; font-family: Arial">
<?=$row['respuesta16'];?>
<input name="C16" type="checkbox" id="C16" value="ON" />
</span></font></div>
<div id="Layer38"><font color="#FFFFFF"><span style="font-size: 12.0pt; font-family: Arial">
<?=$row['respuesta17'];?>
<input name="C17" type="checkbox" id="C17" value="ON" />
</span></font></div>
<div id="Layer39"><font color="#FFFFFF"><span style="font-size: 12.0pt; font-family: Arial">
<?=$row['respuesta18'];?>
<input name="C18" type="checkbox" id="C18" value="ON" />
</span></font></div>
<div id="Layer40"><font color="#FFFFFF"><span style="font-size: 12.0pt; font-family: Arial">
<?=$row['respuesta19'];?>
<input name="C19" type="checkbox" id="C19" value="ON" />
</span></font></div>
<div id="Layer21">
<a href="Resultados.php">
<input type="submit" class="post"name="Submit" value="Votar"/>
</a>
</div>
<p> </p>
</form>
</body>
</html>