<p>Your Name (required)<br />
    [text* your-name] </p>

<p>Your Email (required)<br />
    [email* your-email] </p>

<p>Your Message<br />
    [textarea your-message] </p>

<p>[captchac captcha-626]</p>

<p>[captchar captcha-626]</p>

<p>[submit "Send"]</p>