<label>full name

[text* fullname] </label>

<label>phone number
[text* phonenumber]</label>

<label>City and full address
[text* Cityandfulladdress] </label>

[select* Selectoneoftheoffers “1 grater The Morim, priced at 120 dirhams” “2 graters of The Morem, priced at 220 dirhams”]

[submit “Confirmation”]