Embed

<form style="align:left;padding:2%;">

<p style="align:left;">
<label>First Name
<input type="text" name="customer_name" required>
</label> 
</p>

<p>
<label>Last Name
<input type="text" name="customer_name" required>
</label> 
</p>
<p>
<label>Phone Number
<input type="text" name="Phone Number" required>
</label> 
</p>

<p>
<label>Email 
<input type="email" name="email_address">
</label>
</p>

<p>
<label>Pick-Up Location
<input type="text" name="Pick-Up Location">
</label>
</p>

<p>
<label>Pick-Up Zip Code
<input type="text" name="Pick-Up Zip Code">
</label>
</p>

<p>
<label>Pick-up Address
<input type="text" name="Pick-up Address">
</label>
</p>

<p>
<label>Pickup Date/Time
<input type="datetime-local" name="pickup_time" required>
</label>
</p>

<p>
<label>Delivery Location
<input type="text" name="Delivery Location">
</label>
</p>

<p>
<label>Delivery Zip Code
<input type="text" name="Delivery Zip Code">
</label>
</p>

<p>
<label>Delivery Address
<input type="text" name="Delivery Address">
</label>
</p>

<p>
<label>Delivery Date/Time
<input type="datetime-local" name="pickup_time" required>
</label>
</p>
<h5><br> Dimensions</h5>
<p>
<label>L
<input type="Text">
</label>
</p>
<p>
<label>W
<input type="Text">
</label>
</p>
<p>
<label>H
<input type="Text">
</label>
</p>
<p><br>
<label>Weight
<input type="Text">
</label>
</p>

<fieldset>
<legend>Type of Vehicle Required if known?</legend><br>
<p><label> <input type="radio" name="taxi" value="car"> Car </label></p>
<p><label> <input type="radio" name="taxi" value="Suv"> Suv </label></p>
<p><label> <input type="radio" name="Mini-Van" value="Mini-Van"> Mini-Van </label></p>
<p><label> <input type="radio" name="Cargo-Van"value="Cargo-Van"> Cargo-Van</label></p>
<p><label> <input type="radio" name="16ft Box Truck"value="16ft Box Truck"> 16ft Box Truck </label></p>
<p><label> <input type="radio" name="26Ft Straight/Box Truck" required value="26Ft Straight/Box Truck"> 26Ft Straight/Box Truck </label></p>

</fieldset>

<h5 style="padding-top:2%;padding-bottom:2%;">Will delivery truck need to be dock high to ensure adequate unloading? </h5>
<p><label> <input type="radio" name="Yes" required value="26Ft Straight/Box Truck"> Yes </label></p>
<p><label> <input type="radio" name="Yes" required value="No"> No </label></p>
<br>

<h4 style="background-color:powderblue;text-align:center;padding:2%;"><button type="submit">Send a message</button></h4>

</form>