<?php
$id1 = $_GET['id1'];
$date = $_GET['date'];
$sql = "INSERT INTO test(id1, date)
VALUES ('$id1','$date')";
?>
<form action='script.php' method='get'>
<input type='text' name='id1'>
<input type='text' name='date'>
<input type='submit' value='Submit'>
</form>