input {
  background: none;
  border: 0;
  border-bottom: 3px solid #fff;
  padding: 10px;
}

Some sample code. The icons are missing and the best implementation of font color for placeholders is still disputed.

Where you would like to implement the form?

I did this pen really quick: http://codepen.io/m1aw/pen/pvmyyw

I think is something like this you are looking for.

Not all browsers support color for placeholders with pseudo elements.

Here's my pen it's pretty simple: http://codepen.io/Cdjohnson012895/pen/GgaZNg

But you can play with it to get a better idea of what you want!

Here's my JSFiffle. This code requires Font Awesome, which is super easy to install.

I've replaced the ugly blue focus border with a small animation.

Let me know if you want anything changed.