hedera-web/web/forms/cms/contact/ui.xml

<vn>
<div id="form" class="contact">
	<div class="box">
		<div class="header">
			<h1><t>IWantCustomer</t></h1>
		</div>
		<div class="body">
			<p>
				<t>FillFormData</t>
			</p>
			<p>
				<t>OrCallUs</t>
			</p>
			<form action="forms/cms/contact/send-data.php" method="post" id="contact-form">
				<div class="form-group">
					<label><t>Name</t></label>
					<input type="text" name="name"/>
				</div>
				<div class="form-group">
					<label><t>City</t></label>
					<input type="text" name="city"/>
				</div>
				<div class="form-group">
					<label><t>PC</t></label>
					<input type="text" name="pc"/>
				</div>
				<div class="form-group">
					<label><t>Phone</t></label>
					<input type="text" name="phone"/>
				</div>
				<div class="form-group">
					<label><t>EMail</t></label>
					<input type="text" name="email"/>
				</div>
				<div class="form-group">
					<label><t>Message</t></label>
					<textarea name="message"/>
				</div>
				<div class="form-group captcha">
					<label><t>Anti-Spam</t></label>
					<img alt="Captcha" id="captcha-img"/>
					<input type="text" name="captcha"/>
				</div>
				<p>
					<t>AllFieldsMandatory</t>
				</p>
				<button class="flat">
					<t>Send</t>
				</button>
			</form>
		</div>
	</div>
</div>
</vn>