<p>Uw naam (required)<br />
    [text* your-name] </p>

<p>Uw e-mailadres (required)<br />
    [email* your-email] </p>

<p>Onderwerp<br />
    [text your-subject] </p>

<p>Type hier uw vraag of opmerking<br />
    [textarea your-message] </p>

<p>[submit "Indienen"]</p>