<div class="revolution_form">
    <div class="row">
        <div class="name-wrapper span12">
            <label><span class="label" style="line-height: 50px;height: 50px;font-size: 16px;border: none;">http:// yoursite.com</span>[text* your-name]</label>
            <div class="revolution_form_btn" style="text-align: center;">
                [submit "Analyze your site"]
            </div>
        </div>
    </div>
</div>