<table border="0" width="100%" id="table1" cellspacing="1" cellpadding="2">
     <input type=hidden name=f1 value=моя_почта@gmail.com>
     <tr>
         <td>Ваш email или телефон <font color="red">*</font>:</td>
         <td>
             <input type="text" name="f4" size="30" style="width:95%;" maxlength="70">
         </td>
     </tr>
     <tr>
         <td>Код услуги <font color="red">*</font>:</td>
         <td>
             <label style="display:none;"><input id="fc22" type="checkbox" name="f2" value="002">002</label>
             <label><input id="fc23" type="checkbox" name="f2" value="003">003</label>
         </td>
     </tr>
     <tr>
         <td>Код с картинки <font color="red">*</font>:</td>
         <td>
             <input type="text" name="f5" size="6" maxlength="5">$SECURITY_CODE$</td>
     </tr>
     <tr>
         <td colspan="2" align="center">
             <input type="submit" value="Отправить сообщение">
         </td>
     </tr>
</table>