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I have tried to submit the form and I did not experience any issue while doing so:
Please do let us know if you are still experiencing the same issue, and if so, do let us know if the issue can be recreated over the direct link ( http://form.jotform.us/form/52705235578157 ), or is the issue present where the form is embedded on your own website only?
Based on the screenshot I believe that you were going to it over the direct link, but you found the cause and fixed it :)
I fixed it thanks!
In behalf of my colleague, you are welcome.
Should you need any assistance again, please feel free to contact us.