<p>Name:<br />
    [text* your-name] </p>

<p>Contact By: <br />
[checkbox* checkbox-785 "Phone"]
[checkbox checkbox-856 "Email"]

 </p>

<p>Phone:<br />
  [text Phone] </p>


<p>Email:<br />
    [email* your-email] </p>

<p>Address:<br />
   [text Address]</p>

<p>City, State Zip Code:<br />
 [text City]</p>

<p>Your Message<br />
    [textarea your-message] </p>

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