Make sure all your quotes are double quotes and not single. Also, you need to keep the paragraph tags and the classes with each one.

form.html

<form action="your_action_url" method="post">
<p class="et_bloom_popup_input et_bloom_subscribe_name"> <!-- keep note of the paragraph and the classes being used, you need this -->
	<input type="text" id="input_1" name="q1_control_fname" size="50" placeholder="Name" /> <!-- Placeholder is important -->
</p>
<p class="et_bloom_popup_input et_bloom_subscribe_email">
	<input type="email" class="validate[required, Email]" id="input_4" name="q4_email" size="50" placeholder="Email Address" />
</p>

<button id="input_2" type="submit" class="form-submit-button">Learn How!</button>
</form>