document.write('<div id="out_table">');
document.write('<form action="//amamin.jp/survey_result.php" method="post"><input type="hidden" name="csrf" value="65cf79b3a776216282c51e3b36bb20d8b25411bd" />');
document.write('<div id="survey_title">');
document.write('チョコ何個もらった＆あげた？');
document.write('</div>');
document.write('<div id="survey_time">2014/02/18～2014/03/03</div>');
document.write('<div id="survey_brief">今年のバレンタイン、男性はもらったチョコの数（人数）、女性はあげた数（人数）を教えてください（＾ω＾）</div>');
document.write('<table class="survey_vote">');
document.write('<tr class="survey_vote"><td class="survey_vote"></td><td class="survey_vote"><label for="0">0個</label></td></tr><tr class="survey_vote"><td class="survey_vote"></td><td class="survey_vote"><label for="1">1個</label></td></tr><tr class="survey_vote"><td class="survey_vote"></td><td class="survey_vote"><label for="2">2個</label></td></tr><tr class="survey_vote"><td class="survey_vote"></td><td class="survey_vote"><label for="3">3個</label></td></tr><tr class="survey_vote"><td class="survey_vote"></td><td class="survey_vote"><label for="4">4個</label></td></tr><tr class="survey_vote"><td class="survey_vote"></td><td class="survey_vote"><label for="5">5個</label></td></tr><tr class="survey_vote"><td class="survey_vote"></td><td class="survey_vote"><label for="6">6～10個</label></td></tr><tr class="survey_vote"><td class="survey_vote"></td><td class="survey_vote"><label for="7">11個以上</label></td></tr>');
document.write('</table>');
document.write('');
document.write('<div id="vote_button">');
document.write('<p class="bt"></p>');
document.write('<p class="more"><a href="//amamin.jp/survey_result.php?id=41&page=3">投票結果を見る</a></p>');
document.write('</div>');
document.write('<input type="hidden" name="id" value="41">');
document.write('</form>');
document.write('</div>');