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<form>
	<div class="form-group"> <!-- Email field !-->
		<label for="email_id" class="control-label">Email</label>
		<input type="email" class="form-control" id="email_id" name="email_name" placeholder="name@domain.com">
	</div>
	<div class="form-group"> <!-- Message input !-->
		<label class="control-label " for="message_id">Message</label>
		<textarea class="form-control" id="message_id" name="message" rows="5"></textarea>
	</div>
	<div class="form-group"> <!-- Message input !-->
		<label class="control-label " for="region_id">Message</label>
		<select class="form-control" id="region_id" name="region">
			<option value="North">North</option>
			<option value="West">West</option>
			<option value="East">East</option>
			<option value="South">South</option>
		</select>
	</div>
	
	<div class="form-group"> <!-- Submit button !-->
		<button type="submit" class="btn btn-primary">Submit</button>
	</div>	
</form>