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CSS

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HTML 

              
                <main id="main" class="content">
  <div id="img-div">
    <figure>
      <a href="https://www.youtube.com/watch?v=dPOyOM7wxlE" target="_blank">
        <img id="image"
          src="http://images.fanpop.com/images/image_uploads/Bridge-of-Death-monty-python-and-the-holy-grail-591679_800_441.jpg"
          alt="A still from the Bridge of Death scene in Monty Python and The Holy Grail" />
      </a>
      <figcaption id="img-caption">Monty Python and The Holy Grail: Bridge of Death
        (<a href="https://www.youtube.com/watch?v=dPOyOM7wxlE" target="_blank">YouTube</a>). Source:
        <a href="http://www.fanpop.com/clubs/monty-python-and-the-holy-grail/images/591679/title/bridge-death-screencap"
        target="_blank">Fanpop</a>.
      </figcaption>
    </figure>
  </div>
  <div class="text">
    <h1 id="title">Bridge of Death</h1>
    <h2>Immigration and Customs Enforcement</h2>
    <p id="description"><strong>Stop!</strong> Who would cross the Bridge of Death must answer me these questions three (or more), 'ere the other side he see.</p>
    <p class="note">Items indicated by <span class="required">*</span> are required.</p>
      <form id="survey-form" class="survey" action="submit.html" method="get">
        <label id="name-label" class="field" for="name">What is your name? <span class="required">*</span></label>
        <input id="name" name="name" type="text" placeholder="Sir Launcelot of Camelot" required />
        <label id="email-label" class="field" for="email">What is your email address? <span class="required">*</span></label>
        <input id="email" name="email" type="email" placeholder="launcelot@roundtable.org.uk" required />
        <label id="occupation-label" class="field" for="occupation">What is your occupation?</label>
        <div id="occupation" class="checkboxes">
          <label for="occupation-1" class="checkbox"><input id="occupation-1" type="checkbox" name="occupation" value="King"> King</label>
          <label for="occupation-2" class="checkbox"><input id="occupation-2" type="checkbox" name="occupation" value="Knight"> Knight</label>
          <label for="occupation-3" class="checkbox"><input id="occupation-3" type="checkbox" name="occupation" value="Peasant"> Peasant</label>
          <label for="occupation-4" class="checkbox"><input id="occupation-4" type="checkbox" name="occupation" value="Police Officer"> Police Officer</label>
        </div>
        <label id="oppress-label" class="field" for="oppressed">Is the king oppressing you?</label>
        <div class="radio-buttons">
          <label for="oppressed-yes"><input id="occupation-yes" name="oppressed" type="radio" value="yes" /> Yes</label>
          <label for="oppressed-no"><input id="occupation-no" name="oppressed" type="radio" value="no" /> No</label>
        </div>
        <label id="dropdown-label" class="field" for="dropdown">What is your quest? <span class="required">*</span></label>
        <div class="dropdown">
          <div class="dropdown-options">
            <select id="dropdown" name="quest" class="select-box" required>
              <option value="">None of your business</option>
              <option value="grail">Search for the Holy Grail</option>
              <option value="defeat">Defeat the Black Knight</option>
              <option value="cross">Cross the Bridge of Death</option>
              <option value="rabbit">Lob the Holy Hand Grenade at the Rabbit of Caerbannog</option>
              <option value="other">Other (please specify)</option>
            </select>
          </div>
        </div>
        <label id="other-label" class="field" for="name">If you chose “Other”, briefly describe your quest:</label>
        <input id="other" name="quest-other" type="text" placeholder="I just want to sing" />
        <label id="number-label" class="field" for="number">What is the air-speed velocity of an unladen swallow (in km/h)? <span class="required">*</span></label>
        <input id="number" name="velocity" type="number" placeholder="60" min="0" max="200" required />
        <label id="comments-label" class="field" for="comments">Do you have any other comments before your fate is decided?</label>
        <textarea id="comments" name="comments" rows="6" placeholder="My favourite colour is red. No, blue."></textarea>
        <button id="submit" type="submit">Submit</button>
      </form>
    </div>
  </div>
</main>
!

CSS 

              
                body {
  font: 1rem/1.5rem 'Open Sans', sans-serif;
  color: #333;
  margin: 0;
  padding: 0;
}

a:active,
a:visited,
a:link {
  text-decoration: none;
  color: #00f;
}
a:hover {
  color: #000;
}

div {
  box-sizing: border-box;
}

h1 {
  font-family: 'Raleway', sans-serif;
  font-weight: 300;
  font-size: 2em;
  line-height: 1.3em;
  color: #131313;
  margin-bottom: 0;
}

h2 {
  font-weight: normal;
  font-size: 1em;
  text-transform: uppercase;
  letter-spacing: .1em;
  margin-top: .5em;
}

figure {
  margin: 0;
}

figcaption {
  font-size: .7em;
  line-height: 1.3em;
  padding: .5em 0;
}

#image {
  width: 100%;
  max-width: 100%;
  display: block;
}

#img-caption {
  padding: .5em 1em;
}

.inset img {
  width: 100%;
}

.content {
  padding: 0;
  margin: 0;
  background: #fff;
}

.text {
  padding: .5em 2em 1.5em;
  box-sizing: border-box;
}

.note {
  font-size: .9em;
  font-style: italic;
}

.required {
  color: #f00;
}

aside p {
  font-size: .9em;
  border-top: 1px solid #eee;
  padding: .5em 0 .6em;
  margin: 0;
}

aside {
  border-bottom: 1px solid #eee;
}

::placeholder {
  color: #ccc;
}

input,
select,
textarea {
  box-sizing: padding-box;
}

textarea,
input[type="text"],
input[type="email"],
input[type="number"] {
  color: black;
  font-size: 1em;
  line-height: 1.5em;
  width: 100%;
  box-sizing: border-box;
  padding: .75em;
  margin: .5em 0 1em;
  border: 1px solid #ccc;
}

select {
  background: #fff;
  width: 100%;
  font-size: 1em;
  padding: 1em .75em;
  border: 1px solid #ccc;
  border-radius: 0;
  -webkit-appearance: none;
  -moz-appearance: none;
  text-overflow: '';
}

.dropdown {
  position: relative;
  margin: .5em 0 2em;
}

.dropdown .dropdown-options::after {
  color: #999;
  display: block;
  background: white;
  padding: .5em .3em .4em .8em;
  font-family: "Octicons";
  content: "\f0a3";
  font-size: 1.3em;
  pointer-events: none;
  position: absolute;
  top: .2em;
  right: .2em;
  border-left: 1px solid #eee;
}

label.field {
  font-weight: 700;
  display: block;
  margin-top: .75em;
}

form.submitted input:valid,
form.submitted select:valid,
form.submitted textarea:valid {
  border: 1px solid #ccc;
}

form.submitted input:invalid,
form.submitted select:invalid,
form.submitted textarea:invalid {
  border: 1px solid #f00;
  box-shadow: 0 0 0 2px #f00;
}

.checkboxes,
.radio-buttons {
  margin: .5em 0 1.5em;
}

.checkboxes label,
.radio-buttons label {
  margin-bottom: .5em;
  display: block;
}

button {
  font-size: 1em;
  text-transform: uppercase;
  color: #fff;
  background: #444;
  width: 100%;
  margin: .5em 0 1em;
  padding: 1em .75em;
  border: 1px solid #ccc;
  border-radius: 0;
  -webkit-appearance: none;
  -moz-appearance: none;
}

button:hover {
  background: #000;
}

button:active {
  background: #0ac;
}

@media (min-width: 800px) {

  body {
    background: #ccc url('http://images.fanpop.com/images/image_uploads/Bridge-of-Death-monty-python-and-the-holy-grail-591679_800_441.jpg') no-repeat right top fixed;
    background-color: rgba(255, 255, 255, 0.50);
    background-blend-mode: color;
    background-size: cover;
  }

  h1 {
    font-size: 3em;
  }

  .text h1 {
    margin-top: 0;
  }

  figure.inset {
    float: left;
    width: 45%;
    display: inline;
    margin-right: 5%;
    margin-bottom: 1em;
  }

  .content {
    max-width: 800px;
    margin: 100px auto;
    box-shadow: 0 0 10px #888;
    border-top: 12px solid #131313;
  }

  .content:after {
    content: "";
    display: table;
    clear: both;
  }

  .text {
    padding: 5em 6em 6em;
  }

  .checkboxes label,
  .radio-buttons label {
    margin: 0 1em .5em 0;
    display: inline;
  }

}
!

JS 

              
                document.getElementById("submit").addEventListener("click", function( event ) {
  document.getElementById("survey-form").classList.add("submitted");
});
!
999px

Console