Share your information with Vanessa Small

Vanessa Small

Rebel Escapes

<html>
  <body>
    <form-template>&#13;
	<fields>&#13;
		<field type="header" subtype="h2" label="Contact Info"/>&#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="Phone number" name="phone-number" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Email" name="email" subtype="text" className="form-control"/>&#13;
		<field type="header" subtype="h2" label="Questions for your trip"/>&#13;
		<field type="text" required="true" 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="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" required="true" label="When would you like to return?" 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="checkbox-group" 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="text" required="true" 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" required="true" label="How many adult travelers?" name="number-of-travelers" subtype="text" className="form-control"/>&#13;
		<field type="text" label="How many children (under 18)&amp;nbsp; travelers?" name="text-1750617355374" subtype="text" className="form-control"/>&#13;
		<field type="text" label="What is the age (at the time of travel) of each child?" name="text-1750617434371" subtype="text" className="form-control"/>&#13;
		<field type="radio-group" required="true" label="What is your &quot;PER PERSON&quot; budget for each traveler?" description="This just gives me a general starting point and can always be changed later." name="budget">&#13;
			<option label="$500 to $1,500" value="500-to-1500">$500 to $1,500</option>&#13;
			<option label="$1,500 to $2,500" value="1500-to-2500">$1,500 to $2,500</option>&#13;
			<option label="$2,500 to $4,500" value="2500-to-4500">$2,500 to $4,500</option>&#13;
			<option label="$4,500 to $6,500" value="4500-to-6500">$4,500 to $6,500</option>&#13;
			<option label="$6,500 to $8,000" value="6500-to-8000">$6,500 to $8,000</option>&#13;
			<option label="$8,000+" value="8000">$8,000+</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="checkbox-group" required="true" label="Do you want to add Travel Insurance?" name="checkbox-group-1750617939073">&#13;
			<option label="Yes, please include Travel Insurance" value="yes-please-include-travel-insurance">Yes, please include Travel Insurance</option>&#13;
			<option label="No, I will get Travel Insurance on my own" value="no-i-will-get-travel-insurance-on-my-own">No, I will get Travel Insurance on my own</option>&#13;
		</field>&#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;
		<field type="text" required="true" label="How did you hear about Rebel Escapes?" name="text-1781355971108" subtype="text" className="form-control"/>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>