postToGoogleDocsForm.html

<form id="provcon-form-email" target="_self" onsubmit="" action="javascript:postProvConToGoogleEmail()" style="display:none">
			<div class="alert alert-dismissable alert-warning text-center">
				Thanks!
				<br>
				If you tell us your e-mail address, someone from our team will get back to you very soon to explore how you can start saving!
			</div>
			<div class="form-group">
				<label for="email" class="h4">Email</label>
				<input 
					required="required" 
					id="email"
					type="email" 
					pattern="^[a-zA-Z0-9.!#$%&'*+/=?^_`{|}~-]+@[a-zA-Z0-9-]+(?:\.[a-zA-Z0-9-]+)*$" 
					name="email" 
					class="form-control" 
					placeholder="email@domain.com">
			</div>
			<div class="clear">
		    	<input 
		    		type="submit" 
		    		value="Get in touch!" 
		    		name="submit" 
		    		id="send" 
					class="btn-success btn-lg btn-block">
			</div>
		</form>
		<div style="display:none" class="tryit-submitted alert alert-dismissable alert-warning text-center">
			Thanks!
			<br>
			We'll get back to you very soon to explore how you can start saving!
		</div>

postToGoogleDocsForm.js

function postProvConToGoogleEmail() {
    var insurer = $("#insurer").val();
    var medication = $("#medication").val();
    var email = $('#email').val();
    var postUrl = "";
    
	if ((insurer !== "") && (email !== "") && ((medication !== "") && (validateEmail(email)))) {
        $.ajax({
            url: postUrl,
            data: {
            	"entry.664435950" : insurer, 
            	"entry.1941006211" : medication, 
            	"entry.2103849256": email
        	},
            type: "POST",
            dataType: "xml",
                statusCode: {
                0: function () {
                   	$("#provcon-form-email").hide();
                    $(".tryit-submitted").show();
                    //Success message
                },
                200: function () {
                    $("#provcon-form-email").hide();
                    $(".tryit-submitted").show();
                    //Success Message
                }
            }
        });
    }
    else {
        //Error message
    }
}

function validateEmail(email) {
    var re = /^(([^<>()[\]\\.,;:\s@\"]+(\.[^<>()[\]\\.,;:\s@\"]+)*)|(\".+\"))@((\[[0-9]{1,3}\.[0-9]{1,3}\.[0-9]{1,3}\.[0-9]{1,3}\])|(([a-zA-Z\-0-9]+\.)+[a-zA-Z]{2,}))$/;
    return re.test(email);
}