PTO Form Issue

CAN SOMEONE HELP ME WITH THE CODE BELOW.  I AM RECEIVEING AN ERROR: THERE WAS AN ERROR TRING TO SEND YOUR MESSAGE. PLEASAE TRY AGAIN LATER.  THANK YOU:)


<div class="employee-forms">
  <div class="form-group">
    <label>Today's Date:</label> [date* todays-date]

    [text* name-of-employee class:form-control placeholder "Name Of Employee"]

    [text* job-of-employee class:form-control placeholder "Job Name"]

    [text* number-of-days-requested class:form-control placeholder "Number of Days Requested"]

    <label>Start Date:</label> [date* start-date]

    <label>End Date:</label> [date* end-date]

    <label>Type of Request <span class="required">*</span></label>
    [checkbox* type-of-request "Vacation" "Personal Leave" "Sick Pay" "Funeral/Bereavement" "Jury Duty" "Family or Medical Leave" "Voting" "Other"]

    <label>Has Supervisor Been Notified <span class="required">*</span></label>
    [select* supervisor-notification "Yes" "No"]
  </div>

  <div class="form-group">
    [textarea* comments class:form-control placeholder "Comments"]
  </div>

  <div class="form-group">
    <label>Employee Certification</label>
    [acceptance employee-certification] I understand that time away from work is subject to approval. [/acceptance]
  </div>

  <div class="form-group">
    [submit class:btn btn-default center-block "Submit PTO Request Form"]
  </div>
</div>

The page I need help with: [log in to see the link]