{% block footer_feedback_form %}
	<div class="common-title">
		<h3 class="footer-heading">{{ 'menu.feedback.form'|trans({},'app') }}</h3>
	</div>
	<div class="clearfix"></div>
	<div class="feedback-responsive footer-link">
		<form action="{{ url('office_brain_page_comingsoon_view') }}">
			<div class="row">
				<div class="col-xs-12">
					<div class="form-group">
						<label for="FirstName" class="checkout-label">{{ 'menu.feedback.first_name'|trans({},'app') }}<i class="check-out-mandatory-field">*</i></label>
						<input type="text" data-original-title="First Name" title="" data-placement="bottom" data-toggle="tooltip" tabindex="1" class="input">
					</div>
				</div>
				<div class="col-xs-12">
					<div class="form-group">
						<label for="LastName" class="checkout-label">{{ 'menu.feedback.last_name'|trans({},'app') }}<i class="check-out-mandatory-field">*</i></label>
							<input type="text" data-original-title="Last Name" title="" data-placement="bottom" data-toggle="tooltip" tabindex="1" class="input">
					</div>
				</div>
				<div class="col-xs-12">
					<div class="form-group">
						<label for="Email" class="checkout-label">{{ 'menu.feedback.email'|trans({},'app') }}</label>
						<input type="text" data-original-title="Email" title="" data-placement="bottom" data-toggle="tooltip" tabindex="1" class="input">
					</div>
				</div>
				<div class="col-xs-12">
					<div class="form-group">
						<label for="Message" class="checkout-label">{{ 'menu.feedback.message'|trans({},'app') }}</label>
                		<textarea data-original-title="Message" title="" data-placement="bottom" data-toggle="tooltip" tabindex="1" class="textarea"></textarea>
					</div>
				</div>
				<div class="col-xs-12">
					<input type="submit" tabindex="17" value="Submit" class="btn btn-default">
					<input type="submit" tabindex="17" value="Reset" class="btn btn-default">
					<span class="required">* {{ 'req_fields'|trans({}, 'app') }}</span>
				</div>
			</div>
		</form>
	</div>
{% endblock footer_feedback_form %}