with much trial and error i got it!
Your Name
[text* your-name]
Your Email (required)
[email* your-email]
[checkbox promocheckbox "Select to include promo code"]
[group i-have-a-code]
Promo Code (All codes must be typed lowercase.)
[text code-answer]
[/group]
[group code-is-incorrect]
No promo code has been accurately entered, please uncheck the box to continue without a promo code.
[/group]
[group no-discount][/group]
[group code-is-correct]
Congratulations, you're going to get $5.00 off!
[/group]
[group submit-button]
[submit "Subscribe Now"]
[/group]