Вот код
<form action="index.php" method="post" id="form" onclick="mouseClick();">
<input type="hidden" id="hiddenX" name="hiddenX">
<input type="hidden" id="hiddenY" name="hiddenY">
<div id='centerLayer'>
Number[000]..[999]<input type=text name='number' align="center" list="number"><br/>
X[0..1000]<input type=text name='x' id="mouseX" align=center><br/>
Y[0..1000]<input type=text name='y' id="mouseY" align=center><br/>
Name <input type=text name='name' align=center><input type='submit' id="submit" value='ПОГНАЛИ' align=center><br/>
</div>