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

my $data = do {local $/; <DATA>};

my $template = Template->new();

my $params = {
   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->process(\$data, $params) or die $!;

__DATA__
<form>
[% FOR questions %]
	<p>
	[% question %]<br>
	[% FOR radio %]
		[% UNLESS special %]
		<input type="radio" name="[% regular %]" value="[% value %]">[% label %]<br>
		[% ELSE %]
		<input type="radio" name="[% special %]" value="[% value%]"/>[% label%] (please specify:)
		<input type="text" name="[% text %]"/><br/>
		[% END %]
	[% END %]
[% END %]
<input type="submit">
</form>