gistfile1.html

<form action="http://www.desiringgod.org/Store/donation_process/" method="post">
            <div class="amount"> 
                <h5 style="display:block;width:400px;margin:0 0 10px;">Select the amount of your monthly donation:</h5> 
                <input name="donation[9][amount]" value="5"  type="radio" size="6" /> $5 per month
                <br /><input name="donation[9][amount]" value="15" type="radio" size="6" /> $15 per month
                <br /><input name="donation[9][amount]" value="25" type="radio" size="6" /> $25 per month
                <br /><input name="donation[9][amount]" value="Other" type="radio" size="6" /> 
                <span style="padding:0 3px 0 0;">$</span><input name="donation[9][amount_override]" value="" type="text" size="6" /> per month
                <input type="hidden" name="donation&#91;9&#93;[recurring]" id="donation&#91;9&#93;[recurring]" value="1" /> 
            </div> 
 
            <div class="button"> 
                <input 
                name="PROCEED"
                type="image"
                src="http://cdn.desiringgod.org/images/buttons/btn_donate.png"
                alt="Add Donation to Cart"
                align="left"
                style="border: 0"
                /> 
            <span id="button_text">(You can review your donation on the next page)</span>                   
            </div> 
 
        </form>