Integration not working

Hi
with his code

[text* your-name placeholder akismet:author "Dein Name"]
[email* your-email placeholder akismet:author_email "Deine Emailadresse"]
[mailpoetsignup* mailpoetsignup-78 mailpoet_list_9 mailpoet_list_8 mailpoet_list_7 mailpoet_list_6 mailpoet_list_5 mailpoet_list_4 mailpoet_list_3 default:on “Recieve Our Cape Town Tips?”]
[submit "Get Free Invitation!"]

i get this output
http://pix.toile-libre.org/upload/original/1479064743.png

Thanks
Andy