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.
Oh, and more information about your product and less asking for information (phone nr?) might make people more inclined to register.