Test

[select name="variable_1" value="Ambassador Drive|Lake House|Plymouth"][select name="variable_1" value="Living Room|Dining Room|Cocktail Room"][textarea name="variable_1" default="Item Name"][
[select name="variable_1" value="Scalamandre|Kravet|Kneedler Fauchere"][select name="variable_1" value="Quote #:|Quote|Proforma #:|Estimate #:"][text name="variable_1" default="#"] on 
[date name="variable_1" default="12/30/2019"] for 
[text name="variable_1" default="#"] yards of the following:

Name:[textarea name="variable_1" default="enter"]
Item #:[textarea name="variable_1" default="enter"]
Color:[textarea name="variable_1" default="enter"]
Width:[textarea name="variable_1" default="enter"]
Repeat:[textarea name="variable_1" default="enter"]
Content:[textarea name="variable_1" default="enter"]

[checkbox name="variable_1" value="Shipping to be determined and billed separately"]

Lead Time:[textarea name="variable_1" default="enter"]

Billed[text name="variable_1" default=""]%