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HTML

              
                <div id="container">
  <h1>&bull; Keep in Touch &bull;</h1>
  <div class="underline">
  </div>
  <div class="icon_wrapper">
    <svg class="icon" viewBox="0 0 145.192 145.192">
      <path d="M126.82,32.694c-2.804,0-5.08,2.273-5.08,5.075v2.721c-1.462,0-2.646,1.185-2.646,2.647v1.995    c0,1.585,1.286,2.873,2.874,2.873h20.577c1.462,0,2.646-1.185,2.646-2.647v-3.041c0-1.009-0.816-1.825-1.823-1.825v-2.722    c0-2.802-2.276-5.075-5.079-5.075h-1.985v-3.829c0-3.816-3.095-6.912-6.913-6.912h-0.589h-20.45c0-2.67-2.164-4.835-4.833-4.835    H56.843c-2.67,0-4.835,2.165-4.835,4.835H34.356v-3.384h-9.563v3.384v1.178h-7.061v1.416c-2.67,0.27-10.17,1.424-13.882,5.972    c-1.773,2.17-2.44,4.791-1.983,7.793c0.463,3.043,1.271,6.346,2.128,9.841c2.354,9.616,5.024,20.515,0.549,28.077    C2.647,79.44-3.125,90.589,2.201,99.547c4.123,6.935,13.701,10.44,28.5,10.44c1.186,0,2.405-0.023,3.658-0.068v9.028h-0.296    c-2.516,0-4.558,2.039-4.558,4.558v4.566h100.04v-4.564c0-2.519-2.039-4.558-4.558-4.558h-0.297V84.631h0.297    c2.519,0,4.558-2.037,4.558-4.556v-0.009c0-2.516-2.039-4.556-4.556-4.556l-36.786-0.009V61.973c0-2.193-1.777-3.971-3.972-3.971    v-4.711h0.456c1.629,0,2.952-1.32,2.952-2.949h14.227V34.459h1.658c2.672,0,4.834-2.165,4.834-4.834h20.45v3.069H126.82z     M34.06,75.511c-2.518,0-4.558,2.04-4.558,4.556v0.009c0,2.519,2.042,4.556,4.558,4.556h0.296v24.12l-0.042-1.168    c-15.994,0.574-26.122-2.523-30.106-9.229C-0.464,90.5,4.822,80.347,6.55,77.423c4.964-8.382,2.173-19.774-0.29-29.825    c-0.843-3.442-1.639-6.696-2.088-9.638c-0.354-2.35,0.129-4.3,1.484-5.958c3.029-3.714,9.509-4.805,12.076-5.1v1.233h7.061v1.49    v2.684c-2.403,1.114-4.153,2.997-4.676,5.237H18.15c-0.584,0-1.056,0.474-1.056,1.056v0.83c0,0.584,0.475,1.056,1.056,1.056h1.984    c0.561,2.18,2.304,3.999,4.658,5.092v0.029c0,0-2.282,20.823,16.479,22.099v1.102c0,1.177,0.955,2.133,2.133,2.133h3.297    c1.178,0,2.133-0.956,2.133-2.133V50.135c0-1.177-0.955-2.132-2.133-2.132h-3.297c-1.178,0-2.133,0.955-2.133,2.132    c-1.575-0.235-5.532-1.17-6.635-4.547c2.36-1.092,4.109-2.913,4.669-5.097h1.308c0.722,0,1.309-0.584,1.309-1.308v-0.578    c0-0.584-0.475-1.056-1.056-1.056h-1.539c-0.542-2.332-2.416-4.271-4.968-5.363v-2.559h17.651c0,2.67,2.166,4.835,4.836,4.835 h2.392v15.88h13.639c0,1.629,1.321,2.949,2.951,2.949h0.899v4.711c-2.194,0-3.972,1.778-3.972,3.971v13.529L34.06,75.511z     M95.188,101.78c0,8.655-7.012,15.665-15.664,15.665c-8.653,0-15.667-7.01-15.667-15.665c0-8.647,7.014-15.664,15.667-15.664    C88.177,86.116,95.188,93.132,95.188,101.78z M97.189,45.669h-9.556c0-0.896-0.726-1.62-1.619-1.62H74.494    c-0.896,0-1.621,0.727-1.621,1.62h-8.967v-11.21h33.283V45.669z"></path>
      <path d="M70.865,101.78c0,4.774,3.886,8.657,8.66,8.657c4.774,0,8.657-3.883,8.657-8.657c0-4.773-3.883-8.656-8.657-8.656    C74.751,93.124,70.865,97.006,70.865,101.78z"></path>
    </svg>
  </div>
  <form action="#" method="post" id="contact_form">
    <div class="name">
      <label for="name"></label>
      <input type="text" placeholder="My name is" name="name" id="name_input" required>
    </div>
    <div class="email">
      <label for="email"></label>
      <input type="email" placeholder="My e-mail is" name="email" id="email_input" required>
    </div>
    <div class="telephone">
      <label for="name"></label>
      <input type="text" placeholder="My number is" name="telephone" id="telephone_input" required>
    </div>
    <div class="subject">
      <label for="subject"></label>
      <select placeholder="Subject line" name="subject" id="subject_input" required>
        <option disabled hidden selected>Subject line</option>
        <option>I'd like to start a project</option>
        <option>I'd like to ask a question</option>
        <option>I'd like to make a proposal</option>
      </select>
    </div>
    <div class="message">
      <label for="message"></label>
      <textarea name="message" placeholder="I'd like to chat about" id="message_input" cols="30" rows="5" required></textarea>
    </div>
    <div class="submit">
      <input type="submit" value="Send Message" id="form_button" />
    </div>
  </form><!-- // End form -->
</div><!-- // End #container -->
              
            
!

CSS

              
                @import url(https://fonts.googleapis.com/css?family=Montserrat:400,700);

html {
  font-family: 'Montserrat', Arial, sans-serif;
  -ms-text-size-adjust: 100%;
  -webkit-text-size-adjust: 100%;
}

body {
  background: #F2F3EB;
}

button {
  overflow: visible;
}

button, select {
  text-transform: none;
}

button, input, select, textarea {
  color: #5A5A5A;
  font: inherit;
  margin: 0;
}

input {
  line-height: normal;
}

textarea {
  overflow: auto;
}

#container {
  border: solid 3px #474544;
  max-width: 768px;
  margin: 60px auto;
  position: relative;
}

form {
  padding: 37.5px;
  margin: 50px 0;
}

h1 {
  color: #474544;
  font-size: 32px;
  font-weight: 700;
  letter-spacing: 7px;
  text-align: center;
  text-transform: uppercase;
}

.underline {
  border-bottom: solid 2px #474544;
  margin: -0.512em auto;
  width: 80px;
}

.icon_wrapper {
  margin: 50px auto 0;
  width: 100%;
}

.icon {
  display: block;
  fill: #474544;
  height: 50px;
  margin: 0 auto;
  width: 50px;
}

.email {
	float: right;
	width: 45%;
}

input[type='text'], [type='email'], select, textarea {
	background: none;
  border: none;
	border-bottom: solid 2px #474544;
	color: #474544;
	font-size: 1.000em;
  font-weight: 400;
  letter-spacing: 1px;
	margin: 0em 0 1.875em 0;
	padding: 0 0 0.875em 0;
  text-transform: uppercase;
	width: 100%;
	-webkit-box-sizing: border-box;
	-moz-box-sizing: border-box;
	-ms-box-sizing: border-box;
	-o-box-sizing: border-box;
	box-sizing: border-box;
	-webkit-transition: all 0.3s;
	-moz-transition: all 0.3s;
	-ms-transition: all 0.3s;
	-o-transition: all 0.3s;
	transition: all 0.3s;
}

input[type='text']:focus, [type='email']:focus, textarea:focus {
	outline: none;
	padding: 0 0 0.875em 0;
}

.message {
	float: none;
}

.name {
	float: left;
	width: 45%;
}

select {
  background: url('https://cdn4.iconfinder.com/data/icons/ionicons/512/icon-ios7-arrow-down-32.png') no-repeat right;
  outline: none;
  -moz-appearance: none;
  -webkit-appearance: none;
}

select::-ms-expand {
  display: none;
}

.subject {
  width: 100%;
}

.telephone {
  width: 100%;
}

textarea {
	line-height: 150%;
	height: 150px;
	resize: none;
  width: 100%;
}

::-webkit-input-placeholder {
	color: #474544;
}

:-moz-placeholder { 
	color: #474544;
	opacity: 1;
}

::-moz-placeholder {
	color: #474544;
	opacity: 1;
}

:-ms-input-placeholder {
	color: #474544;
}

#form_button {
  background: none;
  border: solid 2px #474544;
  color: #474544;
  cursor: pointer;
  display: inline-block;
  font-family: 'Helvetica', Arial, sans-serif;
  font-size: 0.875em;
  font-weight: bold;
  outline: none;
  padding: 20px 35px;
  text-transform: uppercase;
  -webkit-transition: all 0.3s;
	-moz-transition: all 0.3s;
	-ms-transition: all 0.3s;
	-o-transition: all 0.3s;
	transition: all 0.3s;
}

#form_button:hover {
  background: #474544;
  color: #F2F3EB;
}

@media screen and (max-width: 768px) {
  #container {
    margin: 20px auto;
    width: 95%;
  }
}

@media screen and (max-width: 480px) {
  h1 {
    font-size: 26px;
  }
  
  .underline {
    width: 68px;
  }
  
  #form_button {
    padding: 15px 25px;
  }
}

@media screen and (max-width: 420px) {
  h1 {
    font-size: 18px;
  }
  
  .icon {
    height: 35px;
    width: 35px;
  }
  
  .underline {
    width: 53px;
  }
  
  input[type='text'], [type='email'], select, textarea {
    font-size: 0.875em;
  }
}
              
            
!

JS

              
                
              
            
!
999px

Console