halcyon/widgets/side_change_local.php

<div class="side_widget stream_options">
<div class="form_title">
<h2>Change instance</h2>
</div>
<form>
<div class="local_instance_wrap">
<input name="local_instance" placeholder="Blank for default" type="text" class="disallow_enter">
</div>
</form>
</div>