I started writing down some critique, but I think I can summarise: polish it. UI elements are not aligned, buttons don't work and "mm" doesn't seem like a valid entry for the month-field.
Oh, and more information about your product and less asking for information (phone nr?) might make people more inclined to register.
Thanks for your feedback guys. I think jeroen is right, It should just clearly say month / year, as the whole idea of the application is to make things simple. instead of mm/yyyy which is very techie and may not be obvious at all to the end user.
Oh, and more information about your product and less asking for information (phone nr?) might make people more inclined to register.