Looking for honest opinions of my website's popup/optin-form.. (NOT Spamming)

JonnyTGood

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Hey everyone.

Im not 100% if this is the correct section for this post, but after going through all the sections it seemed the most appropriate.

Anyway, I have been trying to create a decent optin-form (appears when visitors leave website), and I have absolutely no talent
in this area, but have done the best I can.

I wont link to my website, but here's my final "popup" form:


0-4773-b7ca2a6e1c8f6b644cbf59c08d2435a9.jpg



So basically, if you have any ideas on ways I could improve it, critical or not, id love to hear them!
.. because as you can see, a lot of it is just copying and pasting stuff at this point.


Thanks in advance guys!
Jonny
 
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