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form.html
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<!doctype html>
<html>
<head>
<meta charset="utf-8">
<title>Untitled Document</title>
<style>
label{width:100%;display:block;margin-top:10px;}
li{list-style-type:none;width:100%;height:50px;margin:3px;}
li label{float:left;width:auto;display:inline;}
li input{float:left;clear:left;}
</style>
</head>
<body>
<div style="width:400px;">
<form id="newsletter" action="handle-et-data.php" name="subscribeForm" method="post" novalidate>
<input type="hidden" name="San Diego Monthly Newsletter" value="true" id="leisure">
<input type="hidden" id="pageURL" name="Signup URL" value="http://preview.sandiego.org/newsletter.aspx">
<label for="email">Email<sup>*</sup></label>
<input type="text" name="Email Address" id="emailInput">
<label for="zipcode">Zipcode<sup>*</sup></label>
<input type="text" name="United States Zip Code" id="zipcode">
<label for="first_name">First Name</label>
<input type="text" name="First Name" id="first_name">
<label for="last_name">Last Name</label>
<input type="text" name="Last Name" id="last_name">
<label for="state">State</label>
<select name="US State" id="state" size="1">
<option selected="selected">Select a State</option>
<option value="AL">Alabama</option>
<option value="MS">Mississippi</option>
<option value="OH">Ohio</option>
<option value="WY">Wyoming</option>
</select>
<label for="first_name">Birthday Month and Day (MM/DD)</label>
<input type="text" value="01/01" name="Birthday" id="datepicker" class="hasDatepicker">
<p>Please select which content you'd like to receive.</p>
<ul>
<li><input type="checkbox" id="artsculture" value="true" name="Arts and Culture">
<label>Arts and Culture</label></li>
<li><input type="checkbox" id="diningnightlife" value="true" name="Dining and Nightlife">
<label>Dining and Nightlife</label></li>
<li><input type="checkbox" id="casinos" value="true" name="Casinos">
<label>Casinos</label></li>
</ul>
<input type="submit" id="submit-button" value="Submit">
</form>
</div>
</body>
</html>