Looks like you are using the email address from the form for the from address.
many hosts require that the from address be a valid email address for your domain.
To edit the universal Email settings, open the server behaviors panel and double click the Universal Email server behavior.
For the from Address, Click the From button and set the from address to use a valid email address for your domain.
for the reply to address, you an click the lightning bolt icon and select the email address form element.
you are also leaving the SMTP server and port settings blank, you should double check with the host to see if this is valid. by leaving it blank, it will use the SMTP Server and port from the php.ini file. if these are not set, leaving them blank wont work.