<style></style>
    <style>
        .ai-form-input {
            padding: 10px;
            margin: 10px;
            width: 300px;
            font-size: 16px;
            border: 1px solid #ccc;
            border-radius: 5px;
        }
        .ai-form-button {
            padding: 10px 20px;
            background-color: #007bff;
            color: white;
            border: none;
            border-radius: 5px;
            cursor: pointer;
        }
        .ai-form-button:hover {
            background-color: #0056b3;
        }
    </style>


    <form id="paymentForm">
        <input type="text" id="ai-form-name" class="ai-form-input" placeholder="Name">
        <input type="email" id="ai-form-email" class="ai-form-input" placeholder="Email">
        <input type="number" id="total_amount" class="ai-form-input" placeholder="Total Amount">
        <select id="month" class="ai-form-input">
            <option value="">Select Month</option>
            <option value="January">January</option>
            <option value="February">February</option>
            <option value="March">March</option>
            <option value="April">April</option>
            <option value="May">May</option>
            <option value="June">June</option>
            <option value="July">July</option>
            <option value="August">August</option>
            <option value="September">September</option>
            <option value="October">October</option>
            <option value="November">November</option>
            <option value="December">December</option>
        </select>
        <input type="text" id="admissionNumber" class="ai-form-input" placeholder="Admission Number">
        <button type="submit" class="ai-form-button">Pay Now</button>
    </form>
    
    <script>
        document.getElementById("paymentForm").addEventListener("submit", function(event) {
            event.preventDefault();
            var name = document.getElementById("ai-form-name").value;
            var email = document.getElementById("ai-form-email").value;
            var totalAmount = document.getElementById("total_amount").value;
            var month = document.getElementById("month").value;
            var admissionNumber = document.getElementById("admissionNumber").value;
            
            // Additional code to process the payment or save the data
        });
    </script>