use strict;
use CGI qw(header);
use HTML::Template;

my $data = do {local $/; <DATA>};
my $template = HTML::Template->new(
   scalarref => \$data,
);

$template->param(
   questions => [
      {
         question => 'What is your favorite number?',
         radio => [
            {
               regular => 'question01',
               value   => 'a',
               label   => 5,
            },
            {
               regular => 'question01',
               value   => 'b',
               label   => 7,
            },
            {
               regular => 'question01',
               value   => 'c',
               label   => 13,
            },
            {
               special => 'question01',
               value   => 'd',
               label   => 'Other',
               text    => 'other',
            },
         ],
      },
      {
         question => 'Where did you hear about this product?',
         radio => [
            {
               regular => 'question02',
               value   => 'a',
               label   => 'Friend',
            },
            {
               special => 'question02',
               value   => 'b',
               label   => 'Magazine',
               text    => 'magname',
            },
            {
               regular => 'question02',
               value   => 'c',
               label   => 'Brochure',
            },
            {
               special => 'question02',
               value   => 'd',
               label   => 'Other',
               text    => 'other',
            },
         ],
      },
   ],
);

print header, $template->output;

__DATA__
<form>
<tmpl_loop questions>
   <p>
   <tmpl_var question><br/>
   <tmpl_loop radio>
      <tmpl_unless special>
         <input type="radio" name="<tmpl_var regular>" value="<tmpl_var value>"/><tmpl_var label><br/>
      <tmpl_else>
         <input type="radio" name="<tmpl_var special>" value="<tmpl_var value>"/><tmpl_var label> (please specify:)
         <input type="text" name="<tmpl_var text>"/><br/>
      </tmpl_unless>
   </tmpl_loop>
   </p>
</tmpl_loop>
<input type="submit">
</form>