Someone

<form enctype="multipart/form-data" action="http://www.freedback.com/mail.php" method="post" accept-charset="UTF-8">
	<div>
		<input id="acctid" value="gdo2ewc71pi1xvbr" name="acctid" type="hidden"/>
		<input id="formid" value="364437" name="formid" type="hidden"/>
		<input id="required_vars" value="name,email,field-579273c17c6f30d,field-d40219d8eff9cd3" name="required_vars" type="hidden"/>
	</div>
	<table border="0" cellspacing="5" cellpadding="5">
		<tr>
			<td valign="top">
				<strong>Name:</strong>
			</td>
			<td valign="top">
				<input id="name" value="" name="name" size="10" type="text"/>
				
			</td>
		</tr>
		<tr>
			<td valign="top">
				<strong>Email Address:</strong>
			</td>
			<td valign="top">
				<input id="email" value="" name="email" size="10" type="text"/>
				
			</td>
		</tr>
		<tr>
			<td valign="top">
				<strong>Submission Type:</strong>
			</td>
			<td valign="top">
				<input id="field-579273c17c6f30d_0" value="Dead Link" name="field-579273c17c6f30d" type="radio"/> Dead Link<br/>
				<input id="field-579273c17c6f30d_1" value="Request" name="field-579273c17c6f30d" type="radio"/> Request<br/>
				<input id="field-579273c17c6f30d_2" value="Feedback" name="field-579273c17c6f30d" type="radio"/> Feedback<br/>
				
			</td>
		</tr>
		<tr>
			<td valign="top">
				<strong>Submission:</strong>
			</td>
			<td valign="top">
				<textarea id="field-d40219d8eff9cd3" rows="3" cols="8" name="field-d40219d8eff9cd3"></textarea>
				
			</td>
		</tr>
		<tr>
			<td colspan="2" align="center">
				<input value=" Submit" type="submit"/>
			</td>
		</tr>
	</table>
</form>
<br/><center><font face="Arial, Helvetica" size="1"><b>
</b></font></center>