To: sgray@localhost
Cc: [Email]
Subject: This is a sample form

Name: [Name]
Email: [Email]
Phone: [Phone]
Mailing Address: [Mailaddress]

What sort of person is this?

Adjectives (if checked, the adjective is labelled "on"):
 Angry:       [Angry]         Brooding:    [Brooding]
 Conniving:   [Conniving]     Discreet:    [Discreet]
 Eccentric:   [Eccentric]     Gentle:      [Gentle]
 Haughty:     [Haughty]       Independent: [Independent]
 Jealous:     [Jealous]       Loyal:       [Loyal]
 Mischievous: [Mischievous]   Observant:   [Observant]
 Pious:       [Pious]         Scholarly:   [Scholarly]
 Vengeful:    [Vengeful]      Worldly:     [Worldly]

What else would s/he like me to know?
 [Essay]