<div class="member_feedback">
    <div class="row">
        <div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
            <div class="input-group">
                [text* text-name placeholder akismet:author "First Name"]
            </div>
        </div>
        <div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
            <div class="input-group">
                [text* text-name2 placeholder akismet:author "Last Name"]
            </div>
        </div>
        <div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
            <div class="input-group">
                [email* email placeholder akismet:author_email "E-mail"]
            </div>
        </div>
        <div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
            <div class="input-group">
                [tel phone placeholder "Phone Number"]
            </div>
        </div>
        <div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
            <div class="input-group">
                [text* city placeholder "City"]
            </div>
        </div>
        <div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
            <div class="input-group">
                [select state first_as_label "Select State (USA only)" "Value 1" "Value 2"]
            </div>
        </div>
        <div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
            <div class="input-group">
                [select country first_as_label "Country" "Value 1" "Value 2"]
            </div>
        </div>
        <div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
            <div class="input-group">
                <button type="submit" class="button size-lg icon_left"><i class="fa fa-chevron-right"></i> Submit</button>
            </div>
        </div>
    </div>
</div>