Share your information with Melissa Balduf

Melissa Balduf

<html>
  <body>
    <form-template>&#13;
	<fields>&#13;
		<field type="header" subtype="h2" label="Trip Questionnaire Form"/>&#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 required="true"  type="text" label="Email" name="email" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Phone number" name="phone-number" subtype="text" className="form-control"/>&#13;
		<field type="checkbox-group" label="Where would you like to go on your next adventure?" name="where-would-you-like-to-go-on-your-next-adventure" other="true">&#13;
			<option label="Walt Disney World (Florida)" value="walt-disney-world-florida">Walt Disney World (Florida)</option>&#13;
			<option label="Disneyland (California) " value="disneyland-california-">Disneyland (California) </option>&#13;
			<option label="Universal Studios Orlando" value="universal-studios-orlando">Universal Studios Orlando</option>&#13;
			<option label="Universal Studios Hollywood " value="universal-studios-hollywood-">Universal Studios Hollywood </option>&#13;
			<option label="Disney Cruise " value="disney-cruise-">Disney Cruise </option>&#13;
		</field>&#13;
		<field type="date" label="When would you like to check in?" 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 check out?" description="This just gives me a general idea of when you like to return; it can be changed later." name="ending-at" className="form-control"/>&#13;
		<field type="textarea" label="What are the first and last name of all the adults?" name="what-are-the-first-and-last-name-of-all-the-adults" className="form-control"/>&#13;
		<field type="textarea" label="What are the first and last names of all the children plus their ages?&amp;nbsp;" name="what-are-the-first-and-last-names-of-all-the-children-plus-their-ages-" className="form-control"/>&#13;
		<field type="radio-group" label="What is your budget for all travelers?" description="This just gives me a general starting point and can always be changed later." name="budget">&#13;
			<option label="$2,500 to $4,500" value="2500-4500">$2,500 to $4,500</option>&#13;
			<option label="$4,500 to $6,500" value="4500-6500">$4,500 to $6,500</option>&#13;
			<option label="$6,500 to $8,500" value="6500-8500">$6,500 to $8,500</option>&#13;
			<option label="$8,500 to $10,000" value="8500-10000">$8,500 to $10,000</option>&#13;
			<option label="$10,000+" value="10000">$10,000+</option>&#13;
		</field>&#13;
		<field type="radio-group" label="What best describes your hotel preference?" name="hotel-preference" other="true">&#13;
			<option label="Value" value="value">Value</option>&#13;
			<option label="Moderate" value="moderate">Moderate</option>&#13;
			<option label="Deluxe " value="deluxe-">Deluxe </option>&#13;
		</field>&#13;
		<field type="checkbox-group" label="Do you qualify for any of these possible discounts?&amp;nbsp;" name="do-you-qualify-for-any-of-these-possible-discounts-">&#13;
			<option label="Florida Resident" value="florida-resident">Florida Resident</option>&#13;
			<option label="Disney Chase Visa Cardholder " value="disney-chase-visa-cardholder-">Disney Chase Visa Cardholder </option>&#13;
			<option label="Military (active or 100% disabled)" value="military-active-or-100-disabled">Military (active or 100% disabled)</option>&#13;
			<option label="Annual Passholder" value="annual-passholder">Annual Passholder</option>&#13;
			<option label="Disney+ Subscriber " value="disney-subscriber-">Disney+ Subscriber </option>&#13;
		</field>&#13;
		<field type="textarea" label="What else would you like me to know? (Celebrations, mobility concerns, food allergies, resort requests, etc.)&amp;nbsp;" 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="Were you referred by anyone? We want to be sure to thank them!&amp;nbsp;" name="must-dos" subtype="text" className="form-control"/>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>