Fix Autoresponder code. Not Capturing Email.

Fix Autoresponder code. Not Capturing Email.

Cancelled

Job Description

I need someone to look at the html code on this page.
everything works perfect except that the email used for opt in does not get tracked or loaded into my getresponse account.
I need it fixed asap.

Here is the page.
http://kylerieglelive.com/glead/?leads=17