Share your information with Jessica Roettger

Jessica Roettger

<html>
  <body>
    <form-template>&#13;
	<fields>&#13;
		<field type="header" subtype="h3" label="Trip Questionnaire"/>&#13;
		<field type="paragraph" subtype="p" label="Let&#39;s get your trip planning started! Please complete the form below so I can get to know you and your trip details. I will reach out to you soon!&amp;nbsp;"/>&#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="Phone number" name="phone-number" subtype="text" className="form-control"/>&#13;
		<field type="checkbox-group" required="true" label="Where would you like to travel?" name="checkbox-group-1769694370855" other="true">&#13;
			<option label="Walt Disney World in Florida" value="walt-disney-world-in-florida">Walt Disney World in Florida</option>&#13;
			<option label="Disneyland in California" value="disneyland-in-california">Disneyland in California</option>&#13;
			<option label="Universal Orlando" value="universal-orlando">Universal Orlando</option>&#13;
			<option label="Universal Hollywood " value="universal-hollywood-">Universal Hollywood </option>&#13;
			<option label="Disney Cruise Line" value="disney-cruise-line">Disney Cruise Line</option>&#13;
			<option label="Other Cruise Line" value="other-cruise-line">Other Cruise Line</option>&#13;
			<option label="Other Disney locations ex: Paris" value="other-disney-locations-ex-paris">Other Disney locations ex: Paris</option>&#13;
			<option label="All Inclusive" value="all-inclusive">All Inclusive</option>&#13;
		</field>&#13;
		<field type="text" label="What are your preferred travel dates?" name="text-1769694623473" subtype="text" className="form-control"/>&#13;
		<field type="checkbox-group" label="Are your dates flexible?" name="dates-flexible">&#13;
			<option label="Yes" value="yes">Yes</option>&#13;
		</field>&#13;
		<field type="text" label="Who is in your travel party? (Number of adults and children under 18, with ages of children listed please)" placeholder="ex: 2 adults, 3 kids age 7, 5 and 4" name="number-of-travelers" subtype="text" 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="Do any of these discounts apply to you?&amp;nbsp;" name="checkbox-group-1769694865103">&#13;
			<option label="Active, Retired, or 100% Disabled Military" value="active-retired-or-100-disabled-military">Active, Retired, or 100% Disabled Military</option>&#13;
			<option label="Disney Chase Visa Card Holder" value="disney-chase-visa-card-holder">Disney Chase Visa Card Holder</option>&#13;
			<option label="Florida Resident" value="florida-resident">Florida Resident</option>&#13;
			<option label="California Resident" value="california-resident">California Resident</option>&#13;
			<option label="Annual Passholder" value="annual-passholder">Annual Passholder</option>&#13;
			<option label="Canadian Resident" value="canadian-resident">Canadian Resident</option>&#13;
			<option label="Disney+ Subscriber" value="disney-subscriber">Disney+ Subscriber</option>&#13;
		</field>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>