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HTML
<STYLE TYPE='text/css'>
#loading{
display:none;
vertical-align:relative;
position:relative;
left:0;
top:100;
width:100%;
height:100%;
z-index:1000;}
#loadingcontent{
position:inherit;
left:50%;
top:35%;
width:50%;
height:50%;}
#loadingspinner{
vertical-align:inherit;
width: 20%;
text-align: center;
font-size:larger;} 
textarea { width: 100%; margin: 0; padding: 0; border-width: 1; }
.feedback-summary { width: 100%; margin: 0; padding: 0; border-width: 1; }
BODY, input, select, table {
font-size: 14px;font-family: Arial,Helvetica,FreeSans,'sans - serif';}
</STYLE>

<script src='http://ajax.googleapis.com/ajax/libs/jquery/1.7.1/jquery.min.js'></script> 
<div id="loading">
<div id="loadingcontent">
<img id="loadingspinner" src="http://www.teamlead.ru/download/attachments/25591816/loader.gif?api=v2" alt="Loading"/>
</div>
</div>

<div id='feedback-main-div' style='font-size: 14px; font-family: Arial,Helvetica,FreeSans,sans-serif'>
<div id='feedback-error'></div>


<form class="aui" enctype='multipart/form-data' id='feedback-form' name='feedback-form' target='feedback-response' method='post' action='http://jira.teamlead.ru/plugins/servlet/feedback/create'>
<input type='hidden' name='form-index' id='form-index' value='2'/>

<br> 
 
<div>
<input type='hidden' id='feedback-summary' name='feedback-summary' class='feedback-summary' placeholder='Тема обращения' value='Запрос на хостинг'/>
</div>

<br>
<div style='display:none;'>
<input type='text' id='feedback-language' name='feedback-language' class='feedback-language' placeholder='Выберите язык (en/ru)' value='ru'/>
</div>

<div>
<select class="select" id='customfield_13241' name='customfield_13241'>
<option value='11484' selected>Выберите приложение</option>
<option value='11484'>JIRA<selected>JIRA</option>
<option value='11485'>Confluence</option>
</select>
</div>
 
<div>
<select class="select" id='customfield_12647' name='customfield_12647'>
<option value='' >Пользователей</option>
<option value='11297'>10</option>
<option value='11298'>25</option>
<option value='11299'>50</option>
<option value='11300'>100</option>
</select>
</div>
 
<div>
<input class="text" type='text' id='customfield_12740' name='customfield_12740' placeholder='Придумайте веб-адрес инсталляции' size='38' value=''/>.teamlead.ru (Можно использовать свой домен)
</div>

<br>
<div>
<TEXTAREA class="textarea long-field" id='feedback-body' name='feedback-body' ROWS='5' placeholder='Тут можно указать подробности...'></TEXTAREA>
</div>
<br>
<div>
<input class="text" type='text' id='feedback-email' name='feedback-email' placeholder='Ваш e-mail' size='38' value=''/>
</div>
<br> 
 
<div> 
<input class="aui-button aui-button-primary" type='button' value=' Хочу хостинг! ' onclick='addFeedback()'/>
</div>
</form>
</div>

<iframe id='feedback-response' name='feedback-response' frameborder='no' style='display: none' width='600' height='250'>
</iframe>
 
<div id='feedback-new-issue-div'>
</div>
 
<script type='text/javascript'>
jQuery(window).load(function()
{
   jQuery('#feedback-main-div').show();
   jQuery('#feedback-new-issue-div').hide();
   jQuery('#feedback-response').hide();
   jQuery('#feedback-new-issue-button').click(function ()
   {
    jQuery('#feedback-form')[0].reset();
    jQuery('#feedback-main-div').show();
    jQuery('#feedback-new-issue-div').hide();
    jQuery('#feedback-response').hide();
   });
});

function addFeedback() {
   var summary = jQuery('#feedback-summary').val();
   var email = jQuery('#feedback-email').val();
   if (summary == '' || email == '')
   {
    var message = '';
    if (summary == '')
    {
     message = message + '<div>Введите тему обращения</div>';
    }
    if (email == '')
    {
     message = message + '<div><font color="red">Введите E-mail для ответа</font></div>';
    }
	if (adress.trim() == '') 
	{ 
	message = message + '<div><h3><font color="red">Введите адрес вашей инсталляции</font></h3></div>';
	}
    jQuery('#feedback-error').html(message);
    return false;
}
   jQuery('#feedback-error').html('');
   jQuery('#feedback-main-div').hide();
   jQuery('#loading').fadeIn();
   jQuery('#feedback-response').show();
   jQuery('#feedback-form').submit();
   jQuery('#feedback-response').on("load", function() {
   jQuery('#feedback-new-issue-div').show();
   jQuery('#loading').fadeOut();
}); 
   return false;
}
</script>

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