<link href="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css">
<script src="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/js/bootstrap.min.js"></script>
<script src="//code.jquery.com/jquery-1.11.1.min.js"></script>
<div class="container">
<div class="row">
<div class="col-md-6">
<div class="well-block">
<div class="well-title">
<h2>Questions? Book an Appointment</h2>
</div>
<form>
<div class="row">
<div class="col-md-6">
<div class="form-group">
<label class="control-label" for="name">Name</label>
<input id="name" name="name" type="text" placeholder="Name" class="form-control input-md">
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<label class="control-label" for="email">Email</label>
<input id="email" name="email" type="text" placeholder="E-Mail" class="form-control input-md">
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<label class="control-label" for="date">Preferred Date</label>
<input id="date" name="date" type="text" placeholder="Preferred Date" class="form-control input-md">
</div>
</div>
<div class="col-md-6">