I like the idea. It seems to take up a lot of space though to get a lot of simple information.I think a little color contrast for the form fields will help. I w

I like the idea. It seems to take up a lot of space though to get a lot of simple information.I think a little color contrast for the form fields will help. I would be interested to see how this for would compare to other forms. You should test it with Google optimizer to see which people are more likely to convert. Always test, the data won't lie. You got to go with what gets you more users.