Share your information with Dominique Barba

Dominique Barba

Bliss Travel Service

<html>
  <body>
    <form-template>&#13;
	<fields>&#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" label="Communication Preference" name="communication-preference" other="true">&#13;
			<option label="Email" value="email">Email</option>&#13;
			<option label="Phone" value="phone">Phone</option>&#13;
		</field>&#13;
		<field type="checkbox-group" label="Which Distinctive Voyages sailing are you interested in?" name="which-distinctive-voyages-sailing-are-you-interested-in" other="true">&#13;
			<option label="Seabourn Alaska June 2026" value="seabourn-alaska-june-2026">Seabourn Alaska June 2026</option>&#13;
			<option label="Holland America UK &amp; Ireland August 2026" value="holland-america-uk-ireland-august-2026">Holland America UK &amp; Ireland August 2026</option>&#13;
			<option label="Celebrity New Zealand Oct 2026" value="celebrity-new-zealand-oct-2026">Celebrity New Zealand Oct 2026</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 travelers?" name="number-of-travelers" subtype="text" className="form-control"/>&#13;
		<field type="text" label="If children please list ages at time of travel." name="if-children-please-list-ages-at-time-of-travel" subtype="text" className="form-control"/>&#13;
		<field type="checkbox-group" label="Are you celebrating anything on this vacation?" name="are-you-celebrating-anything-on-this-vacation" other="true">&#13;
			<option label="Destination Wedding" value="destination-wedding">Destination Wedding</option>&#13;
			<option label="Honeymoon" value="honeymoon">Honeymoon</option>&#13;
			<option label="Anniversary" value="anniversary">Anniversary</option>&#13;
			<option label="Birthday" value="birthday">Birthday</option>&#13;
			<option label="Retirement" value="retirement">Retirement</option>&#13;
			<option label="Graduation" value="graduation">Graduation</option>&#13;
		</field>&#13;
		<field type="radio-group" required="true" label="What is your PER PERSON price range?" description="This just gives me a general starting point and can always be changed later." name="budget">&#13;
			<option label="$2,000 to $3,000" value="2000-to-3000">$2,000 to $3,000</option>&#13;
			<option label="$3,000 to $4,000" value="3000-to-4000">$3,000 to $4,000</option>&#13;
			<option label="$4,000 to $5,500" value="4000-to-5500">$4,000 to $5,500</option>&#13;
			<option label="$5,500 to $7,500" value="5500-to-7500">$5,500 to $7,500</option>&#13;
			<option label="$7,500 to $10,000" value="7500-to-10000">$7,500 to $10,000</option>&#13;
			<option label="$10,000+" value="10000">$10,000+</option>&#13;
		</field>&#13;
		<field type="radio-group" required="true" label="Does this include airfare?" name="does-this-include-airfare">&#13;
			<option label="Yes" value="yes">Yes</option>&#13;
			<option label="No" value="no">No</option>&#13;
		</field>&#13;
		<field type="radio-group" required="true" label="Have you cruised before?" name="have-you-cruise-before">&#13;
			<option label="Yes" value="yes">Yes</option>&#13;
			<option label="No" value="no">No</option>&#13;
		</field>&#13;
		<field type="checkbox-group" required="true" label="Cabin choice" name="cabin-choice">&#13;
			<option label="Suite" value="suite">Suite</option>&#13;
			<option label="Balcony" value="balcony">Balcony</option>&#13;
			<option label="Ocean view" value="ocean-view">Ocean view</option>&#13;
			<option label="Inside" value="inside">Inside</option>&#13;
		</field>&#13;
		<field type="checkbox-group" required="true" label="Preferred dining time." name="preferred-dining-time">&#13;
			<option label="Set early time (around 6pm)" value="set-early-time-around-6pm">Set early time (around 6pm)</option>&#13;
			<option label="Set late time (around 8:30pm)" value="set-late-time-around-830pm">Set late time (around 8:30pm)</option>&#13;
			<option label="Flexible time (may require separate reservations)" value="flexible-time-may-require-separate-reservations">Flexible time (may require separate reservations)</option>&#13;
		</field>&#13;
		<field type="checkbox-group" required="true" label="How big do you want your table size?" name="how-big-do-you-want-your-table-size">&#13;
			<option label="Just the people in my party" value="just-the-people-in-my-party">Just the people in my party</option>&#13;
			<option label="It would be nice to meet another couple or two" value="it-would-be-nice-to-meet-another-couple-or-two">It would be nice to meet another couple or two</option>&#13;
			<option label="The more the merrier" value="the-more-the-merrier">The more the merrier</option>&#13;
		</field>&#13;
		<field type="checkbox-group" label="Beds pushed together or apart?" name="beds-pushed-together-or-apart">&#13;
			<option label="Beds pushed together" value="beds-pushed-together">Beds pushed together</option>&#13;
			<option label="Beds apart" value="beds-apart">Beds apart</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;
	</fields>&#13;
</form-template>
  </body>
</html>