<p>Your Name (required)<br />
    [text* your-name] </p>

<p>Your Email (required)<br />
    [email* your-email] </p>

<p>Your Mobile Number (required)<br />
    [tel* your-mobile]</p>

<p>Your Company/Organization (required)<br />
    [text* your-company] </p>

<h3>Purpose</h3>

<p>Is your website primarily for information only or for marketing purposes?<br />
    [text your-purpose] </p>

<p>What is your immediate need at the moment?<br />
    [text your-need] </p>

<p>What are your challenges now in Internet marketing?<br />
    [text your-challenges] </p>

<h3>Scope of Work</h3>

<p>Are we constructing your website from scratch?<br />
    [text your-construction] </p>

<p>Do you already have a domain name? i.e. domainname.com <br />
    [text your-domain] </p>

<p>Are you giving us a free hand to create a website that is fit for you based on our extensive knowledge in this field?<br />
    [text your-freehand] </p>

<p>Are you providing graphics materials for the website?<br />
    [text your-graphics] </p>

<p>Are you providing us with text contents?<br />
    [text your-texts] </p>

<p>Are you asking us to make a website that you can control on your own?<br />
    [text your-cms] </p>

<p>After the work is done, are you getting us as consultant on a retainer's basis?<br />
    [text your-retainer] </p>

<p>How much retainer's fee are you willing to pay monthly?<br />
    [text your-retainersfee] </p>

<p>What is your budget range for this kind of project?<br />
    [text your-budget] </p>

<p>When would you need this project completed?<br />
    [text your-deadline] </p>

<h3>Website Details</h3>

<p>Would you like a responsive website? It means the website adjusts depending on the device being used.<br />
    [text your-responsive] </p>

<p>Would you like it to appear on Google search result page?<br />
    [text your-googlesearch] </p>

<p>Would you like it to be socially connected?<br />
    [text your-social] </p>

<p>Would you like to install a blog in your website?<br />
    [text your-blog] </p>

<p>Would you like the website to be shareable?<br />
    [text your-shareable] </p>

<p>Do you have someone to help maintain the website?<br />
    [text your-maintain] </p>

<p>Would you like us to train your team to handle the website?<br />
    [text your-train] </p>

<h3>Competition</h3>

<p>Who are you competing with?<br />
    [text your-competition] </p>

<p>How does their presence affect your business?<br />
    [text your-effect] </p>

<p>Would you know their websites and social media accounts?<br />
    [text your-competitors] </p>

<h3>Other instructions</h3>

<p>Your Message<br />
    [textarea your-message] </p>

<p>[submit "Send"]</p>