Edit in JSFiddle

<h5>Pobierz wartość kursu &euro; NBP wg. daty</h5>               
 <div>                           
	<div class="left">
		<select class="form" id="kurs_data_dzien" name="kurs_data_dzien">
			<option value="01" >01</option>                             
			<option value="02" >02</option>                             
			<option value="03" >03</option>                             
			<option value="04" >04</option>                             
			<option value="05" >05</option>                             
			<option value="06" >06</option>                             
			<option value="07" >07</option>                             
			<option value="08" >08</option>                             
			<option value="09" >09</option>                             
			<option value="10" >10</option>                             
			<option value="11" >11</option>                             
			<option value="12" >12</option>                             
			<option value="13" >13</option>                             
			<option value="14" >14</option>                             
			<option value="15" >15</option>                             
			<option value="16" >16</option>                             
			<option value="17" >17</option>                             
			<option value="18" >18</option>                             
			<option value="19" >19</option>                             
			<option value="20" >20</option>                             
			<option value="21" >21</option>                             
			<option value="22" >22</option>                             
			<option value="23" >23</option>                             
			<option value="24" >24</option>                             
			<option value="25" >25</option>                             
			<option value="26" >26</option>                             
			<option value="27" >27</option>                             
			<option value="28" >28</option>                             
			<option value="29" >29</option>                             
			<option value="30" >30</option>                             
			<option value="31" >31</option>
		</select>
	</div>
                            
	<div class="left center">
		<select class="form" id="kurs_data_miesiac" name="kurs_data_miesiac">
			<option value="01" >01</option>                             
			<option value="02" >02</option>                             
			<option value="03" >03</option>                             
			<option value="04" >04</option>                             
			<option value="05" >05</option>                             
			<option value="06" >06</option>                             
			<option value="07" >07</option>                             
			<option value="08" >08</option>                             
			<option value="09" >09</option>                             
			<option value="10" >10</option>                             
			<option value="11" >11</option>                             
			<option value="12" >12</option> 
		</select>
	</div>
	
	<div class="left center">
		<select class="form" id="kurs_data_rok" name="kurs_data_rok">
			<option value="2015" >2015</option>                             
			<option value="2016" >2016</option>
		</select> 
	</div>                      
	
	<div class="clearboth"></div>

	<input type="button" id="getRate" value="Pobierz i wstaw"/>

</div>          
          
<div>
	<h5 class="form">Kurs &euro; NBP</h5> 
	<input class="form" id="kurs_euro1" type="text" name="kurs_euro1" size="1" maxlength="1" placeholder="0" style="text-align:right;" />,<input class="form" type="text" id="kurs_euro2" name="kurs_euro2" size="4" maxlength="4" placeholder="0000" {POLE_EUR}/>       
	<span id="kurs-result" class="formerror"></span>
</div>                  
                                
<div>
	 <h5 class="form">Tabela NBP</h5> 
		<input class="form" type="text" id="tabela_nbp" name="tabela_nbp" size="16" maxlength="16" placeholder="nnn/A/NBP/20nn" style="text-align:right;"><br />         
	 <span class="formerror"></span>            
</div>