gistfile1.js

jQuery.getJSON('http://freegeoip.net/json/', function(location) {
    var d          = new Date(),
        curr_date  = d.getDate(),
        curr_month = d.getMonth(),
        curr_year  = d.getFullYear(),
        fulldate   = curr_date + "-" + curr_month + "-" + curr_year;
    $('<input id="date" type="hidden" name="custom_date" value="' + full_date + '" />').appendTo($('#your-form-id-here'));
    $('<input id="ip" type="hidden" name="custom_ip" value="' + location.ip + '" />').appendTo($('#your-form-id-here'));
    $('<input id="country" type="hidden" name="custom_country" value="' + location.country_name + '" />').appendTo($('#your-form-id-here'));
});