<div class="clearfix">
    <div id="left">
        First name [text firstname] <br/>
        Last Name [text lastname] <br/>
    </div>
    <div id="right">
        Email [email* your-email] <br/>
        Phone [text your-phone] <br/>
        Include Breakfast [checkbox checkbox-941 exclusive "YES"] <br/>
        Include Service [checkbox checkbox-857 exclusive "YES"] <br/>
        Arrival [date date-372 id:Arrival date-format:mm/dd/yy inline] Departure [date date-410 id:Departure date-format:mm/dd/yy inline]<br>
    </div>
 
Subject [text* your-subject] <br/>
Message [textarea* your-message] <br/>
[submit "Send"]