FYI that form fails hard on Mobile Safari if you happen to rotate. Form elements go offscreen and you can't pinch zoom your way back to them.
https://www.dropbox.com/s/yyykioemk8z0pqy/Photo%20Dec%2030%2...
https://www.dropbox.com/s/6jbmiifu9y5qabd/Photo%20Dec%2030%2...
https://www.dropbox.com/s/q7sq5ztyrafkyly/Photo%20Dec%2030%2...