document.write('<form action="http://support.mailtank.com/web/messages/create/4" method="post">')
document.write('<label for="name">Name:</label><br/>')
document.write('<input id="name" name="name" maxlength="255" type="text" class="textfield" /><br/>')
document.write('<label for="email">Email:</label><br/>')
document.write('<input id="email" name="email" maxlength="255" type="text" class="textfield" /><br/>')
document.write('<label for="subject">Subject:</label><br/>')
document.write('<input id="subject" name="subject" maxlength="255" type="text" class="textfield" /><br/>')
document.write('<label for="message">Message:</label><br/>')
document.write('<textarea id="message" name="message" rows="5" class="textarea"></textarea><br/>')
document.write('<input type="submit" name="submit" value="Send message" id="submit" /><br/>')
document.write('<p style="font-family: Helvetica, Arial, sans-serif;color: #000;font-weight: bold;font-size: 11px;text-align: left; padding: 0 0 15px; margin: 0;">Powered by <a href="http://mailtank.com" style="font-family: Helvetica, Arial, sans-serif;color: #000;font-weight: bold;font-size: 10px;">Mailtank</a>.</p>')
document.write('</form>')