<div class="support">
  <form method="POST">
    <div class="fieldgroup fieldgroup-name">
       <label>Name</label>
       <input type="text" placeholder="First" name="first"/>
       <input type="text" placeholder="Last" name="last"/>
    </div>
    <div class="fieldgroup fieldgroup-site">
       <label>Email</label>
       <input type="text" placeholder="Email Address"/>
    </div>
    <div class="fieldgroup fieldgroup-site">
       <label>Site</label>
       <input type="text" placeholder="Home URL"/>
    </div>
    <div class="fieldgroup fieldgroup-issue-url">
       <label>Issue</label>
       <input type="text" placeholder="Issue URL"/>
    </div>
    <div class="fieldgroup fieldgroup-issue-url">
       <label>Product</label>
       <select>
         <option>UberMenu</option>
       </select>
    </div>

    <div class="fieldgroup fieldgroup-license">
       <label>License</label>
       <input type="text" placeholder="License Code"/>
    </div>
    <div class="fieldgroup fieldgroup-question">
       <label>Question</label>
      <textarea></textarea>
    </div>
    <input type="submit" value="Submit Ticket" />
  </form>
</div>
body{
  background:#eee;
  font-family:Roboto;
}
.support{
  max-width:650px;
  margin:50px auto;
}
.support *{
  -webkit-box-sizing:border-box;
  -ms-box-sizing:border-box;
  -moz-box-sizing:border-box;
  box-sizing:border-box;
}
.support label{
  width:100px;
  color:#aaa;
  display:block;
  float:left;
  vertical-align:top;
  padding:16px 0;
}
.support .fieldgroup{
  margin-bottom:10px;
}
.support input,
.support textarea,
.support select{
  padding:20px;
  font-size:13px;
  width:550px;
  border:none;
  float:left;
  
  background:#f9f9f9;
  border-radius:2px;
}
.support input:focus,
.support textarea:focus{
  outline-color:#0064FF;
}
.fieldgroup{
  display:block;
  clear:both;
  margin-bottom:10px;
}
.fieldgroup:after{
  content:'';
  display:block;
  clear:both;
}
.fieldgroup-name input{
  width:270px;
}
.fieldgroup-name input[name="first"]{
  margin-right:10px;
}
.support textarea{
  height:200px;
}
.support input[type="submit"]{
  float:right;
  color:#fff;
  font-weight:bold;
  background:#0064FF;
  font-size:16px;
}

External CSS

This Pen doesn't use any external CSS resources.

External JavaScript

  1. https://cdnjs.cloudflare.com/ajax/libs/jquery/2.1.3/jquery.min.js