index.html

<div data-role="page">
  <div data-role="header" data-theme="d">
    <h1><img src="http://www.precisionnutrition.com/wordpress/wp-content/themes/pn2012/images/pn_logo.png"/></h1>
  </div>
  <div data-role="content">
    <p>Please enter your contact info below and we'll send your free stuff.</p>
    <form action="http://get.pn/free" method="post">
      <fieldset data-role="fieldcontain">
        <label for="firstName">
            First Name
        </label>
        <input id="firstName" name="firstName"/>
      </fieldset>
      <fieldset data-role="fieldcontain">
        <label for="lastName">
            Last Name
        </label>
        <input id="lastName" name="lastName"/>
      </fieldset>
      <fieldset data-role="fieldcontain">
        <label for="email">
          Best email address
        </label>
        <input id="email" type="email" name="email"/>
      </fieldset>
      <input data-icon="check" data-theme="b" type="submit" value="Send my free stuff!"/>
    </form>
  </div>
</div>