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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It looks like a script conflict is happening between your website and of your form. Could you try removing your embed code and re-embed using the iFrame embed code instead? Here's a guide on how to get your iFrame code: http://www.jotform.com/help/148-Getting-the-Form-iFrame-Code
Let us know if that works.