<link href="//maxcdn.bootstrapcdn.com/bootstrap/4.0.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css">
<script src="//maxcdn.bootstrapcdn.com/bootstrap/4.0.0/js/bootstrap.min.js"></script>
<script src="//code.jquery.com/jquery-1.11.1.min.js"></script>
<div class="feedback feedback-toggle rotate">Schedule Visit</div>
<div class="feedback feedback-form-wrapper">
<form id="feedback-form" class="form-horizontal" method="post">
<legend>Schedule 24 Tech Support Visit</legend>
<div class="form-group">
<label class="sr-only">Your Name</label>
<input id="username" name="username" class="form-control" autocomplete="off" placeholder="Your Name *" required="required" type="text">
</div>
<div class="form-group">
<label class="sr-only">Email ID</label>
<input name="emailquery" id="emailquery" class="form-control" autocomplete="off" placeholder="Your Email *" required="required" type="email">
</div>
<div class="form-group">
<label class="sr-only">Phone Number</label>
<input name="phoneno" id="phoneno" class="form-control" autocomplete="off" placeholder="Phone Number *" required="required" type="number">
</div>
<div class="form-group">
<label class="sr-only">Issue</label>
<textarea id="issue" name="issue" class="form-control" rows="3" autocomplete="off" placeholder="Write Your Issue *" required="required"></textarea>
</div>
<div class="form-group">
<label class="control-label">I need service on</label>
<input class="form-control" name="dateOfReg" id="dateOfReg" autocomplete="off" placeholder="02/03/2014" required="required" min="2015-05-1" type="text">
</div>
<div class="form-group">
<button type="submit" name="sendissuedetails" id="sendissuedetails" class="btn btn-default">Send Details</button>
</div>
</form>
</div>