Share your information with Jacq Miller

Jacq Miller

Flamingo Lane | A Division of The Pixie Planners

<html>
  <body>
    <form-template>&#13;
	<fields>&#13;
		<field type="header" subtype="h1" label="Disney &amp;amp; Theme Park Travel&amp;nbsp;"/>&#13;
		<field type="paragraph" subtype="p" label="Paragraph"/>&#13;
		<field type="header" subtype="h1" label="Traveler Details"/>&#13;
		<field type="text" required="true" label="First name" name="first-name" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Last name" name="last-name" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Email" name="email" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Phone number" name="phone-number" subtype="text" className="form-control"/>&#13;
		<field type="textarea" required="true" label="Please list the names and birthdays of each traveler." name="please-list-the-names-and-birthdays-of-each-traveler" className="form-control"/>&#13;
		<field type="checkbox-group" required="true" label="Which Disney destination are you planning to visit?" name="which-disney-destination-are-you-planning-to-visit">&#13;
			<option label="Walt Disney World (Orlando, FL)" value="walt-disney-world-orlando-fl" selected="selected">Walt Disney World (Orlando, FL)</option>&#13;
			<option label="Disneyland (California)" value="disneyland-california">Disneyland (California)</option>&#13;
			<option label="Disneyland (Paris)" value="disneyland-paris">Disneyland (Paris)</option>&#13;
			<option label="Universal Studios (Orlando, Florida)" value="universal-studios-orlando-florida">Universal Studios (Orlando, Florida)</option>&#13;
			<option label="Universal Studios Hollywood (California)" value="universal-studios-hollywood-california">Universal Studios Hollywood (California)</option>&#13;
		</field>&#13;
		<field type="checkbox-group" required="true" label="Are there other attractions you’d like to visit in the area?&amp;nbsp;" name="are-there-other-attractions-youd-like-to-visit-in-the-area-">&#13;
			<option label="SeaWorld" value="seaworld">SeaWorld</option>&#13;
			<option label="Legoland" value="legoland">Legoland</option>&#13;
			<option label="Other" value="other">Other</option>&#13;
		</field>&#13;
		<field type="header" subtype="h1" label="General Trip Info"/>&#13;
		<field type="date" required="true" label="When would you like to depart?" description="This just gives me a general idea of when you like to go; it can be changed later." name="starting-at" className="form-control"/>&#13;
		<field type="date" label="When would you like to return?" name="ending-at" className="form-control"/>&#13;
		<field type="checkbox-group" required="true" label="How many days do you plan to spend in the theme parks?&amp;nbsp;" name="how-many-days-do-you-plan-to-spend-in-the-theme-parks-">&#13;
			<option label="1-2 days" value="12-days">1-2 days</option>&#13;
			<option label="3-4 days" value="34-days">3-4 days</option>&#13;
			<option label="5 or more days" value="5-or-more-days">5 or more days</option>&#13;
		</field>&#13;
		<field type="checkbox-group" required="true" label="Are your dates flexible?" name="dates-flexible">&#13;
			<option label="Yes" value="yes">Yes</option>&#13;
			<option label="No" value="no">No</option>&#13;
		</field>&#13;
		<field type="textarea" required="true" label="What is your reason for travel? Will you be celebrating anything special? If so, please share the date(s).&amp;nbsp;" name="reason-for-travel" className="form-control"/>&#13;
		<field type="radio-group" label="What is your estimated total budget you are comfortable with (not including airfare)?" description="This just gives me a general starting point and can always be changed later." name="budget">&#13;
			<option label="Under $5,000" value="under-5000">Under $5,000</option>&#13;
			<option label="$5,000 to $10,000" value="5000-to-10000">$5,000 to $10,000</option>&#13;
			<option label="$10,000-$15,000" value="1000015000">$10,000-$15,000</option>&#13;
			<option label="$15,000+" value="15000">$15,000+</option>&#13;
		</field>&#13;
		<field type="text" required="true" label="If you have an exact budget you would like to share, please do!" name="if-you-have-an-exact-budget-you-would-like-to-share-please-do" subtype="text" className="form-control"/>&#13;
		<field type="radio-group" required="true" label="What level of accommodations do you prefer?&amp;nbsp;" name="hotel-preference" other="true">&#13;
			<option label="Budget-Friendly" value="budgetfriendly">Budget-Friendly</option>&#13;
			<option label="Mid-Range Comfort" value="midrange-comfort">Mid-Range Comfort</option>&#13;
			<option label="Luxury" value="luxury">Luxury</option>&#13;
		</field>&#13;
		<field type="text" required="true" label="What hotel/resort amenities are important to you?" description="Ex: swim up bar on-site restaurant pool spa etc." name="what-hotelresort-amenities-are-important-to-you" subtype="text" className="form-control"/>&#13;
		<field type="checkbox-group" required="true" label="Would you like help with dining reservations?" name="would-you-like-help-with-dining-reservations">&#13;
			<option label="Option 1" value="option-1" selected="selected">Option 1</option>&#13;
		</field>&#13;
		<field type="header" subtype="h1" label="Additional Details"/>&#13;
		<field type="text" required="true" label="How did you hear about us? Tell us who we can thank!" name="must-dos" subtype="text" className="form-control"/>&#13;
		<field type="textarea" label="Is there anything else you would like us to know?" description="What else would you like me to know about your travelers  budget and/or travel preferences?" name="notes" className="form-control"/>&#13;
		<field type="text" label="Text Field" name="text-1741717233385" subtype="text" className="form-control"/>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>