<!-- Small Survey -->
<div class="admin-form theme-alert" id="survey1">
    <div class="panel panel-alert heading-border">
        <div class="panel-heading">
            <span class="panel-title"><i class="fa fa-comments"></i> Simple survey</span>
        </div>
        <!-- end .form-header section -->

        <form method="post" action="/" id="form-survey1">
            <div class="panel-body p25">
                <div class="section-divider mt10 mb40">
                    <span>Personal Details</span>
                </div>
                <!-- .section-divider -->

                <div class="section row">
                    <div class="col-md-6">
                        <div class="section">
                            <label for="names" class="field-label">Your names</label>
                            <label for="names" class="field prepend-icon">
                                <input type="text" name="names" id="names" class="gui-input" placeholder="Enter first name...">
                                <label for="names" class="field-icon"><i class="fa fa-user"></i>
                                </label>
                            </label>
                        </div>
                        <!-- end section -->

                        <div class="section">
                            <label for="othernames" class="field-label">Other names</label>
                            <label for="othernames" class="field prepend-icon">
                                <input type="text" name="othernames" id="othernames" class="gui-input" placeholder="Enter other name...">
                                <label for="othernames" class="field-icon"><i class="fa fa-user"></i>
                                </label>
                            </label>
                        </div>
                        <!-- end section -->

                        <div class="section">
                            <label for="email" class="field-label">Your email address</label>
                            <label for="email" class="field prepend-icon">
                                <input type="email" name="email" id="email" class="gui-input" placeholder="Enter Email...">
                                <label for="email" class="field-icon"><i class="fa fa-envelope"></i>
                                </label>
                            </label>
                        </div>
                        <!-- end section -->

                    </div>
                    <!-- end .colm section -->

                    <div class="col-md-6">
                        <div class="section">
                            <label for="mobile" class="field-label">Telephone / mobile</label>
                            <label for="mobile" class="field prepend-icon">
                                <input type="tel" name="mobile" id="mobile" class="gui-input" placeholder="Enter mobile">
                                <label for="mobile" class="field-icon"><i class="fa fa-phone-square"></i>
                                </label>
                            </label>
                        </div>
                        <!-- end section -->

                        <div class="section">
                            <label for="firstaddr" class="field-label">Street address</label>
                            <label for="firstaddr" class="field prepend-icon">
                                <input type="text" name="firstaddr" id="firstaddr" class="gui-input" placeholder="Street address">
                                <label for="firstaddr" class="field-icon"><i class="fa fa-map-marker"></i>
                                </label>
                            </label>
                        </div>
                        <!-- end section -->

                        <div class="section">
                            <label for="city" class="field-label">Home city</label>
                            <label for="city" class="field prepend-icon">
                                <input type="text" name="city" id="city" class="gui-input" placeholder="City">
                                <label for="city" class="field-icon"><i class="fa fa-building-o"></i>
                                </label>
                            </label>
                        </div>
                        <!-- end section -->

                    </div>
                    <!-- end .colm section -->

                </div>
                <!-- end .section row section -->

                <div class="section-divider mv40">
                    <span>Our services</span>
                </div>
                <!-- .section-divider -->

                <div class="section row">
                    <div class="col-md-4">
                        <label class="option block">
                            <input type="checkbox" name="service" value="marketing">
                            <span class="checkbox"></span>Marketing</label>
                        <label class="option block mt10">
                            <input type="checkbox" name="service" value="motion">
                            <span class="checkbox"></span>Motion graphics</label>
                        <label class="option block mt10">
                            <input type="checkbox" name="service" value="videos">
                            <span class="checkbox"></span>Videography</label>
                    </div>
                    <!-- end .colm section -->

                    <div class="col-md-4">
                        <label class="option block">
                            <input type="checkbox" name="service" value="webdesign">
                            <span class="checkbox"></span>Webdesign</label>
                        <label class="option block mt10">
                            <input type="checkbox" name="service" value="webhosting">
                            <span class="checkbox"></span>Web hosting</label>
                        <label class="option block mt10">
                            <input type="checkbox" name="service" value="wordpress">
                            <span class="checkbox"></span>Wordpress CMS</label>
                    </div>
                    <!-- end .colm section -->

                    <div class="col-md-4">
                        <label class="option block">
                            <input type="checkbox" name="service" value="apps">
                            <span class="checkbox"></span>Mobile apps</label>
                        <label class="option block mt10">
                            <input type="checkbox" name="service" value="info">
                            <span class="checkbox"></span>Infographics</label>
                        <label class="option block mt10">
                            <input type="checkbox" name="service" value="icons">
                            <span class="checkbox"></span>Icon design</label>
                    </div>
                    <!-- end .colm section -->

                </div>
                <!-- end .section row section -->

                <div class="section-divider mv40">
                    <span>How can we reach you</span>
                </div>
                <!-- .section-divider -->

                <div class="section">
                    <div class="option-group field">
                        <label for="tv" class="option">
                            <input type="radio" name="reach" id="tv" value="tv">
                            <span class="radio"></span>Television</label>
                        <label for="int" class="option">
                            <input type="radio" name="reach" id="int" value="int">
                            <span class="radio"></span>Internet</label>
                        <label for="paper" class="option">
                            <input type="radio" name="reach" id="paper" value="paper">
                            <span class="radio"></span>Newspaper</label>
                        <label for="radios" class="option">
                            <input type="radio" name="reach" id="radios" value="radios">
                            <span class="radio"></span>Radio</label>
                        <label for="othermedia" class="option">
                            <input type="radio" name="reach" id="othermedia" value="othermedia">
                            <span class="radio"></span>Other media</label>
                    </div>
                </div>
                <!-- end .section section -->

            </div>
            <!-- end .form-body section -->
            <div class="panel-footer">
                <button type="submit" class="button btn-primary">Submit</button>
            </div>
            <!-- end .form-footer section -->
        </form>
    </div>
    <!-- end .admin-form section -->
</div>
<!-- end: .admin-form -->