Share your information with Andrea Hermann

Andrea Hermann

Breakthrough Travel

<html>
  <body>
    <form-template>&#13;
	<fields>&#13;
		<field type="header" subtype="h2" label="Questions for your trip"/>&#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" label="Where would you like to go?" description="If you&#39;re not sure  just give me a few destinations you&#39;re considering." placeholder="ex: Tahiti" name="destination" subtype="text" className="form-control"/>&#13;
		<field type="text" label="When would you like to travel?" name="when-would-you-like-to-travel" subtype="text" className="form-control"/>&#13;
		<field type="text" label="What is your departure city?" description="Where will you be flying from?" name="departure-city" subtype="text" className="form-control"/>&#13;
		<field type="text" label="How many travelers?" name="number-of-travelers" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Guest 1 Name" name="guest-1-name-and-birthdate" subtype="text" className="form-control"/>&#13;
		<field type="date" label="Guest 1 Birthdate" name="guest-1-birthdate" className="form-control"/>&#13;
		<field type="text" label="Guest 2 Name" name="text-1770217379612" subtype="text" className="form-control"/>&#13;
		<field type="date" label="Guest 2 Birthdate" name="guest-2-birthdate" className="form-control"/>&#13;
		<field type="text" label="Guest 3 &amp;nbsp;Name" name="guest-3-name" subtype="text" className="form-control"/>&#13;
		<field type="date" label="Guest 3 Birthdate" name="guest-3-birthdate" className="form-control"/>&#13;
		<field type="text" label="Guest 4" name="guest-4" subtype="text" className="form-control"/>&#13;
		<field type="date" label="Guest 4 Birthdate" name="guest-4-birthdate" 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="$1,500 to $2,500" value="1500-2500">$1,500 to $2,500</option>&#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="Economy" value="value">Economy</option>&#13;
			<option label="Moderate" value="moderate">Moderate</option>&#13;
			<option label="Luxury" value="luxury">Luxury</option>&#13;
			<option label="Boutique" value="boutique">Boutique</option>&#13;
		</field>&#13;
		<field type="checkbox-group" label="What kind of vibe are you looking for?" description="Check all that apply." name="vibe-preference" other="true">&#13;
			<option label="Romantic" value="romantic">Romantic</option>&#13;
			<option label="Rest and relaxation" value="rest-and-relaxation">Rest and relaxation</option>&#13;
			<option label="Off the beaten path" value="off-the-beaten-path">Off the beaten path</option>&#13;
			<option label="Party" value="party">Party</option>&#13;
			<option label="Local culture" value="local-culture">Local culture</option>&#13;
			<option label="Family friendly" value="family-friendly">Family friendly</option>&#13;
			<option label="Food and wine" value="food-wine">Food and wine</option>&#13;
		</field>&#13;
		<field type="checkbox-group" label="What activities are you interested in?" description="Check all that apply" name="activity-preferences" other="true">&#13;
			<option label="Beach and water" value="beach-water">Beach and water</option>&#13;
			<option label="Gambling" value="gambling">Gambling</option>&#13;
			<option label="Scuba" value="scuba">Scuba</option>&#13;
			<option label="Adventure activities" value="adventure">Adventure activities</option>&#13;
			<option label="Golf" value="golf">Golf</option>&#13;
			<option label="Nightlife" value="nightlife">Nightlife</option>&#13;
			<option label="Arts and theater" value="art-theater">Arts and theater</option>&#13;
		</field>&#13;
		<field type="text" label="Anything you absolutely must do or see?" name="must-dos" subtype="text" className="form-control"/>&#13;
		<field type="textarea" label="What else would you like me 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;
	</fields>&#13;
</form-template>
  </body>
</html>