<label>Name
<input name="customer_name" required="" type="text" />
</label>
</p>
<p>
<label>Phone
<input name="phone_number" type="tel" />
</label>
</p>
<p>
<label>Email
<input name="email_address" type="email" />
</label>
</p>
<fieldset>
<legend>Which phone do you want?</legend>
<p><label> <input name="taxi" required="" type="radio" value="car" /> Redmi </label></p>
<p><label> <input name="taxi" required="" type="radio" value="van" /> Samsung </label></p>
<p><label> <input name="taxi" required="" type="radio" value="tuktuk" /> Nokia </label></p>
</fieldset>
<fieldset>
<legend>Extras</legend>
<p><label> <input name="extras" type="checkbox" value="baby" /> Mobile Cover </label></p>
<p><label> <input name="extras" type="checkbox" value="wheelchair" /> Power Bank </label></p>
<p><label> <input name="extras" type="checkbox" value="tip" /> Mobile Stand </label></p>
</fieldset>
<p>
<label>Pickup Date/Time
<input name="pickup_time" required="" type="datetime-local" />
</label>
</p>
<p>
<label>Pickup Place
<select id="pickup_place" name="pickup_place">
<option selected="selected" value="">Select One</option>
<option value="office">Mobile Office</option>
<option value="town_hall">Mobile Store</option>
<option value="telepathy">Mobile Care</option>
</select>
</label>
</p>
<label>Dropoff Place
<select id="pickup_place" name="pickup_place">
<option selected="selected" value="">Select One</option>
<option value="office">Airport</option>
<option value="town_hall">Railway Station</option>
<option value="telepathy">Bashtec House Manigam</option>
</select>
</label>
<p>
</p>
<p>
<label>Special Instructions
<textarea maxlength="500" name="comments"></textarea>
</label>
</p>
<p><button>Submit Booking</button></p>
</div></form>