FORM NAME COULD GO HERE

NAME OF FIRST INPUT ITEM AS SEEN BY USER
NAME OF SECOND INPUT ITEM AS SEEN BY USER
NAME OF THIRD INPUT ITEM AS SEEN BY USER
SOMETHING LIKE A QUESTION COULD GO HERE:
  1. CHOICE 1
  2. CHOICE 2
  3. CHOICE 3
NAME OF FOURTH INPUT ITEM AS SEEN BY USER
SOMETHING LIKE A QUESTION COULD GO HERE:
  1. CHOICE 1
  2. CHOICE 2
  3. CHOICE 3