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HTML 

              
                
<link href="//netdna.bootstrapcdn.com/font-awesome/4.0.3/css/font-awesome.css" rel="stylesheet">
<link href='https://fonts.googleapis.com/css?family=IM+Fell+English+SC' rel='stylesheet' type='text/css'>

<div class="wrapper">
  <div class="outer">
    <div id="container">
      <div id="logo">
        <p>Our Jean Team Is Ready To Seam!</p>
      </div>
      <div id="pocket">
        
        <form id="help_form">
           <div class="igroup"><span class="addon">
             <i class="fa fa-user fa-lg"></i></span>
            <input type="text" id="name" name="name" placeholder="Your First &amp; Last Name"
                 class="form-control">
           </div>
          <div class="igroup"><span class="addon">
            <i class="fa fa-envelope fa-lg"></i></span>
            <input type="text" id="email" name="email" placeholder="Your Email Address"
                 class="form-control">
          </div>

          <h4>What Seams To Be The Problem?</h4>
           <textarea id="ques" cols="50" rows="5"></textarea>
            <button>Send Your Inquiry!</button>
        </form>
        <span class="seam seams"></span>
        <!--<span class="seam s-left"></span>
        <span class="seam s-right"></span>-->
      </div>
    </div>
  </div>
</div>
<div id="success_outer">
  <div id="success_dialog">
    <header>
      <span>Success!</span>
      <button>X</button>
    </header>
    <div id="dialog_body">
      <img src="http://www.clipartbest.com/cliparts/LcK/ger/LcKgerKca.png">
      <p>Yep! That was a success!</p>
    </div>
  </div>
</div>
!

CSS 

              
                .wrapper{
  max-width: 900px;
  margin:0 auto;
}
.outer{
  max-width:100%;
  display:block;
  margin: 0 auto;
  background-color:#E4E7EA;
}

form {
  padding: 14% 10%;
  float:left;
  display: block;
  position:relative;
  max-width:90%;
  text-align:center; 
  z-index: 2;
}
.igroup, .form-control{
  display: table-cell;
  width:92%;
}
.igroup{
  position: relative;
  display: table;
  border-collapse: separate;
  margin: 5px 0;
}
.addon{
  display: table-cell;
  min-width:19px; 
  padding: 6px 12px;
  font-size: 14px;
  font-weight: normal;
  line-height: 1;
  text-align: center;
  background: rgb(238,238,238);
  background: rgba(238,238,238,0.4);
  border: 1px dashed #E0B02B;
  -moz-border-radius: 4px;
  -webkit-border-radius: 4px;
  border-radius: 4px;
  border-bottom-right-radius: 0;
  border-top-right-radius: 0;
}
.addon, .form-control{
  white-space: nowrap;
  vertical-align: middle;
}

.addon:first-child{
  border-right: 0;
}

textarea{
  display:block;
  width: 98%;
  margin-left:0px;
  background: rgb(33,77,104);
  background: rgba(33,77,104,0.6);
  color:#e5e5e5;
  font-size:15px;
  font-family: 'IM Fell English SC', serif;
  border: 1px dashed #E0B02B;
}
h4{
  padding:0;
  margin:10px 0 0 0;
  font-size:16px;
  color: #e5e5e5;
  text-shadow: 0px 2px 3px #2A333D;
  font-family: 'IM Fell English SC', serif;
}
input {
  margin: 0em;
  font: -webkit-small-control;
  color: #e5e5e5;
  letter-spacing: normal;
  word-spacing: normal;
  text-transform: none;
  text-indent: 0px;
  text-shadow: none;
  display: inline-block;
  text-align: start;
  display:block;
  width: 100%;
  border: 1px dashed #E0B02B;
}
.form-control {
  -moz-border-radius: 3px;
  -webkit-border-radius: 3px;
  border-radius: 3px;
  padding: 10px;
  background: rgb(33,77,104);
  background: rgba(33,77,104,0.6);
  height: auto;
  -moz-box-shadow: none;
  -webkit-box-shadow: none;
  box-shadow: none;
  font-size: 14px;
  font-family: 'IM Fell English SC', serif;
  width: 100%;
  border-bottom-left-radius: 0;
  border-top-left-radius: 0;
}

.form-control:focus {
   border-color: #999;
   -moz-box-shadow: none;
   -webkit-box-shadow: none;
   box-shadow: none;
   -moz-box-shadow: 3px 3px 0 rgba(12,12,12,0.05);
   -webkit-box-shadow: 3px 3px 0 rgba(12,12,12,0.05);
   box-shadow: 3px 3px 0 rgba(12,12,12,0.05);
}
button{
  background-color: #314B66;
  border: 1px dashed #E0B02B;
  display: inline-block;
  margin: 10px 0 0 0;
  font-weight: 400;
  text-align: center;
  vertical-align: middle;
  cursor: pointer;
  font-family: 'IM Fell English SC', serif;
  white-space: nowrap;
  padding: 6px 12px;
  font-size: 14px;
  line-height: 1.428;
  border-radius: 4px;
  color: #e5e5e5;
}
button:hover{
  background-color: #406070;
}
#container {
    height: 400px;
    padding: 50px;
    background: url(http://www.wallchan.com/images/sandbox/27365-mac-jeans-pattern-patterns.jpg) -100px -100px;
}
#logo{
    position: relative;
    margin: 0 auto;
    max-width: 300px;
    padding:8px;
    background-color: #BF0000;
    	background-image: radial-gradient(50% 55%, circle cover, rgba(182,0,0,0.2) 0%, rgba(116,0,0,0) 120%);
	    background-image: -webkit-radial-gradient(50% 55%, circle cover, rgba(182,0,0,1) 0%, rgba(116,0,0,1) 120%);
	    background-image: -moz-radial-gradient(50% 55%, circle cover, rgba(182,0,0,0.2) 0%, rgba(116,0,0,0) 120%);
    
    -moz-border-radius: 5px;
    -webkit-border-radius: 5px;
    border-radius: 10px;
    text-align:center;
   box-shadow: 0 4px 12px rgba(0,0,0,0.8), 0 -2px 1px rgba(0,0,0,0.2);
}
#logo:before {
    border: 1px dashed #C5971B;
    -moz-border-radius: 5px;
    -webkit-border-radius: 5px;
    border-radius: 10px;
    content:"";
    display:block;
    position:relative; 
    width:100%; 
    height:9px;
    margin-bottom: 8px;
    background:transparent;
}
#logo:after {
    border: 1px dashed #C5971B;
    -moz-border-radius: 5px;
    -webkit-border-radius: 5px;
    border-radius: 10px;
    content:"";
    display:block;
    position:relative;
    margin-top:5px;
    width:100%; 
    height:4px;                          
    background:transparent;
}
#logo p{
  padding:0;
  margin:0;
  font-size:16px;
  font-weight: bold;
  color: #4a0000;
  text-shadow: 0px 2px 3px #cf0000;
  font-family: 'IM Fell English SC', serif;
}
#pocket {
    position: relative;
    margin: 15px auto;
    max-width: 330px;
    height: 350px;
    box-shadow: 0 5px 10px rgba(0,0,0,0.8), 0 -2px 6px rgba(0,0,0,0.7);
    border-bottom-left-radius: 120px 100px;
    border-bottom-right-radius: 120px 100px;
	background-image: radial-gradient(50% 55%, circle cover, rgba(255,255,255,0.2) 0%, rgba(0,0,0,0) 120%);
	background-image: -webkit-radial-gradient(50% 55%, circle cover, rgba(255,255,255,0.2) 0%, rgba(0,0,0,0) 120%);
	background-image: -moz-radial-gradient(50% 55%, circle cover, rgba(255,255,255,0.2) 0%, rgba(0,0,0,0) 120%);
}
.seam, .seam::before, .seam::after {
    position: absolute;
    border: 2px dashed #E0B02B;
}
.seams {
    width: 96%;
    height: 345px;
    left: 2%;
    border-top-width: 0;
    border-bottom-left-radius: 115px 95px;
    border-bottom-right-radius: 115px 95px;
}
.seams::before {
    content: '';
    height: 15px;
    width: 100%;
    top: 20px;
    left: -1%;
    border-width: 2px 0;
}
.seams::after {
    content: '';
    width: 89%;
    height: 330px;
    left: 5%;
    border-top-width: 0;
    border-bottom-left-radius: 100px 80px;
    border-bottom-right-radius: 100px 80px;
}
.s-left {
    width: 48%;
    height: 50px;
    top: 120px;
    left: 2%;
    border-width: 2px 2px 0 0;
    border-top-right-radius: 215px 75px;
}
.s-left::after {
    content: '';
    width: 100%;
    height: 60px;
    top: 15px;
    border-width: 2px 2px 0 0;
    border-top-right-radius: 200px 95px;
}
.s-right {
    width: 47%;
    height: 50px;
    top: 120px;
    right: 2%;
    border-width: 2px 0 0 2px;
    border-top-left-radius: 215px 75px;
}
.err{
  border: 1px dashed #BF0000;
}
.s-right::after {
    content: '';
    width: 99%;
    height: 60px;
    top: 15px;
    right: 0;
    border-width: 2px 0 0 2px;
    border-top-left-radius: 200px 95px;
}
#success_outer{
  background-color: transparent;
  background: rgba(0,0,0,.5);
  width:100%;
  height:100%;
  position: absolute;
  z-index: 30;
  top:0px;
  left:0px;
  display:none;
}
#success_dialog{
  display:block;
  position:relative;
  background-color:#c0c0c0;
  max-width:30%;
  margin: 0 auto;
  margin-top:120px;
  border: 1px solid #111;
  -moz-border-radius: 5px;
  -webkit-border-radius: 5px;
  border-radius: 10px;
}
#success_dialog header{
  padding:15px;
  display:block;
  background-color:#a5a5a5;
  max-width:100%;
  clear:both;
  border-bottom: 1px solid #111111;
  border-top-left-radius:10px 10px;
  border-top-right-radius:10px 10px;
}
#success_dialog header button{
  float:right;
  margin: 0;
  clear:both;
}
#success_dialog header span{
  font-size: 25px;
  font-family: 'IM Fell English SC', serif;
}
#dialog_body{
  position:relative;
  margin: 0 auto;
  max-width: 50%;
  text-align:center;
}
#success_dialog img{
  max-width: 221px;
  margin: 0;
}
#success_dialog p{
  padding: 0px;
  margin: 10px;
  font-size: 25px;
  font-family: 'IM Fell English SC', serif;
}
!

JS 

              
                $(function(){
    $('#help_form').submit(function(e){
      e.preventDefault();
      if ($('#name').val() === ''){
        $('#name').addClass('err');
        $('#name').focus();
        return false;
      }
      if ($('#email').val() === ''){
        $('#email').addClass('err');
        $('#email').focus();
        return false;
      }
      if ($('#ques').val() === ''){
        $('#ques').addClass('err');
        $('#ques').focus();
        return false;
      }
      $('#success_outer').css({display:'block'});
    });
  $('#success_dialog header button').click(function(){
      $('#success_outer').hide();  
  });
  $('#help_form input, #help_form textarea').blur(function(){
    if ($(this).hasClass('err')){
      $(this).removeClass('err');
    }
    if ($(this).val() !== ''){
      $(this).addClass('suc');
    }else{
      $(this).addClass('err');
    }
  });
});
!
999px

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