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JotForm is a free online form builder which helps you create online forms without writing a single line of code. No sign-up required.
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I see no problem in the form. If there's a thing that prevents you from submitting the form or something that prevents the form from working properly, then I would suggest re-embedding the form using our iFrame method: http://www.jotform.com/help/148-Getting-the-Form-iFrame-Code. In most cases, iFrame embed method should help prevent these issues.