<form class="mt-40 mb-40">
  <input type="hidden" id="uuid" value="">
  <input type="hidden" id="token" value="">
  <label for="email">Email</label>
  <input type="text" id="email_4" name="email_4" value="" placeholder="example@email.com">
  <label for="comment">Reason</label>
  <textarea id="reason_4" placeholder="Your comment here" id="comment">
  </textarea>
  <a href="#" id="account_delete_button" class="btn btn-primary btn-block fw-700">Save</a>
</form>