<label> Country 
    [select countries "United States of America" "United Kingdom" "Japan" "France" "India" "Italy" "United Arab Emirates" "Russian Federation"] </label>

<label> Your Email (required)
    [email* your-email] </label>

<label> Phone Number (required)
    [text* phone] </label>

<div class="nasa-full-width nasa-clear-both padding-top-10 padding-bottom-10 radio-list-wrap">
<label> <input type="radio" name="request-mode" value="Call" checked />&nbsp;&nbsp;Call </label><label> <input type="radio" name="request-mode" value="SMS" />&nbsp;&nbsp;SMS </label><label> <input type="radio" name="request-mode" value="WhatsApp" />&nbsp;&nbsp;WhatsApp </label>
</div>

<div class="nasa-submit-wrap">[submit "Send"]</div>