gistfile1.html

<div class="contact-pop" data-popout="">
    <form action="#" class="custom">
        <a href="#" data-close="" class="pop-close">x</a>
        <div class="row">
            <div class="six columns">
                <label for="date"><input type="text" name="date" id="date" placeholder="ON THIS DATE" data-customforms="disabled"></label>
            </div>
            <div class="six columns">
                <label for="time"><select name="time" id="time">
                    <option selected value="now"> At This Time </option> <option value="morning"> Morning </option>
                    <option value="afternoon"> Afternoon </option>
                    <option value="evening"> Evening </option>
                    <option value="night"> Night </option>
                </select></label>
            </div>
        </div><!--.row-->
        <div class="row">
            <div class="twelve columns">
                <label for="message">Message</label> 
                <textarea name="message" id="" cols="30" rows="5"></textarea>
            </div>
        </div>
        <div class="row">
            <div class="eleven columns offset-by-one">
                <ul class="link-list services">
                    <li> <img src="images/layout/phixer-keyexchange.png" alt=""> </li>
                    <li> <img src="images/layout/phixer-bagcheck.png" alt=""> </li>
                    <li> <img src="images/layout/phixer-translator.png" alt=""> </li>
                    <li> <img src="images/layout/phixer-helper.png" alt=""> </li>
                </ul>
            </div>
        </div>
        <div class="row">
            <div class="six columns offset-by-five">
                <input type="submit" value="Send Message »" class="button primary radius">
            </div>
        </div>
    </form>
</div>