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            <form method='post' class="php-email-form" id="form_do" name="form_do" action="<yang:gbookaddurl />"> 

              <div class="form-row">

                <div class="col-lg-6 form-group">

                  <input type="text" name="name" class="form-control" id="inputUsername" placeholder="Your Name" data-rule="minlen:4" data-msg="Please enter at least 4 chars" />

                  <div class="validate"></div>

                </div>

                <div class="col-lg-6 form-group">

                  <input type="email" class="form-control" name="email" id="inputEmail" placeholder="Your Email" data-rule="email" data-msg="Please enter a valid email" />

                  <div class="validate"></div>

                </div>

              </div>

              <div class="form-group">

                <textarea id="inputContent" class="form-control" name="message" rows="5" data-rule="required" data-msg="Please write something for us" placeholder="primary coverage"></textarea>

                <div class="validate"></div>

              </div>

              <div class="mb-3">

                <div class="loading">Loading</div>

                <div class="error-message"></div>

                <div class="sent-message"></div>

              </div>

              <div class="text-center">

                <button type="submit" id="submit">Send Message</button>

              </div>

            </form>

          </div>