Share your information with Jessica Benjamin

Jessica Benjamin

<html>
  <body>
    <form-template>&#13;
	<fields>&#13;
		<field type="header" subtype="h2" label="Trip Inquiry Form"/>&#13;
		<field type="header" subtype="h2" label="Full name"/>&#13;
		<field type="text" label="Prefix" name="prefix" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="First name" name="first-name" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Middle name" name="middle-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" label="Preferred name" name="preferred-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="radio-group" label="Preferred method of contact" name="preferred-method-of-contact">&#13;
			<option label="Call" value="call">Call</option>&#13;
			<option label="Text" value="text">Text</option>&#13;
			<option label="Email" value="email">Email</option>&#13;
		</field>&#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="date" 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" 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;
		</field>&#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" required="true" label="How many travelers?" name="number-of-travelers" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Age of Travelers (if under 18, please include date of birth)" name="age-of-travelers-if-under-18-please-include-date-of-birth" subtype="text" className="form-control"/>&#13;
		<field type="radio-group" label="If traveling internationally, do you have a current passport?" name="if-traveling-internationally-do-you-have-a-current-passport">&#13;
			<option label="yes" value="yes">yes</option>&#13;
			<option label="not yet" value="not-yet">not yet</option>&#13;
			<option label="applied for and waiting" value="applied-for-and-waiting">applied for and waiting</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="radio-group" label="What is your bed preference?" name="what-is-your-bed-preference">&#13;
			<option label="2 Double/2 Queens" value="2-double2-queens">2 Double/2 Queens</option>&#13;
			<option label="King" value="king">King</option>&#13;
		</field>&#13;
		<field type="radio-group" label="What is your preferred room category?" name="what-is-your-preferred-room-category">&#13;
			<option label="Theme Park View" value="theme-park-view">Theme Park View</option>&#13;
			<option label="Garden/Resort View" value="gardenresort-view">Garden/Resort View</option>&#13;
			<option label="Partial Ocean View" value="partial-ocean-view">Partial Ocean View</option>&#13;
			<option label="Ocean View" value="ocean-view">Ocean View</option>&#13;
			<option label="Ocean Front" value="ocean-front">Ocean Front</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="text" required="true" label="What is your budget?" name="what-is-your-budget" subtype="text" className="form-control"/>&#13;
		<field type="textarea" label="What else would you like me to know?" name="notes" className="form-control"/>&#13;
		<field type="radio-group" label="Where are you at in the planning process?" name="radio-group-1781231408337">&#13;
			<option label="Open to all suggestions" value="open-to-all-suggestions">Open to all suggestions</option>&#13;
			<option label="I know where we want to go, but need recommendations on places to stay" value="i-know-where-we-want-to-go-but-need-recommendations-on-places-to-stay">I know where we want to go, but need recommendations on places to stay</option>&#13;
			<option label="I know where we want to go and where we want to stay, just help me book" value="i-know-where-we-want-to-go-and-where-we-want-to-stay-just-help-me-book">I know where we want to go and where we want to stay, just help me book</option>&#13;
		</field>&#13;
		<field type="radio-group" label="How soon are you wanting to book?" name="how-soon-are-you-wanting-to-book">&#13;
			<option label="ASAP" value="asap">ASAP</option>&#13;
			<option label="Within the month" value="within-the-month">Within the month</option>&#13;
			<option label="Within a couple months" value="within-a-couple-months">Within a couple months</option>&#13;
			<option label="Just considering my options" value="just-considering-my-options">Just considering my options</option>&#13;
		</field>&#13;
		<field type="text" label="How did you find me?" name="text-1781231228177" subtype="text" className="form-control"/>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>